THE SUPERIOR LIMB

The superior limb is connected to the superior-lateral part of the thorax having the
following limits:
- up – the superiorsurface of the clavicle, acromioclavicular joint and the superior
border of scapula.
- down – a horizontal line connecting the points of detatchment of the two axillary
folds from the thoracic wall;
- anterior – a line drawn from the middle of the clavicle to the inferior edge of the
anterior axillary fold;
- posterior – medial edge of scapula.
This delimitation includes theupper limb’ssoft tissue(locatedbetween the limb, and
thethorax)that forms thearmpit(Axilla),and the territory corresponding tothe posterior surface
ofscapula. We want to emphasize this, because this delimitation of the upper limb meets
anatomic-functional, anatomic-topographic, and clinical criteria. Although it is contrary to
anatomical terminology;where the theaxillary regionis considered asa region ofthe thoracic
wall,and thescapular regionas a regionof the back.
The upper limb consists of the following 6 parts:
- Shoulder, or shoulder region; it corresponds to pectoral arch, and represents the
upper limb’s root which made from the ensemble of the formations that connect the arm to
thorax.
- Arm (Brachium).
- Elbow(Cubitus); the segment connecting the forearm to arm. We mention that the
term “cubitus” is used for this purpose and not to name the ulna.
- Forearm(Antebrachium).
- Wrist(Carpus); the anatomical assembly connecting the hand to forearm.
- Hand (Manus) with the five fingers (Digiti manus); in the latero-medial direction
we name the following: Pollex (thumb), Index (pointer finger), Digitus medius (middle
finger), Digitus anularis (ring finger) and Digitus minimus (little finger).
 THE INFERIOR LIMB

The inferior (pelvic) limbs are attached to the infero-lateral parts of the trunk, with
pelvic girdle incorporated into the bony pelvis. The limbs are adapted for support and bipedal
locomotion. Therefore, they possess a solid skeleton, strong joints, and well developed
muscular groups. The limits which separate the inferior limb from the torso are:
- Anterior: the inguinal fold
- Medial: the genitofemural groove (Sulcus femoroperinealis) which separates the
thigh from the perineum
- Posterior: the iliac crest and the intergluteal groove.
The inferior limb is made out of:
- The hip (Coxa), which consists of the pelvic girdle and the soft tissue thatoverlaps the
coxofemural joint and the coxal bone.
- The thigh (Femur): the “femur” is an ambiguous term, because it also refers to the
femur bone.
- The knee (Genus) – the link between the thigh and the leg.
- The leg (Crus).
- The ankle: the narrowed segment which connects the leg and the foot.
- The foot (Pes) has five toes that are numbered from medial to lateral from I to V. The
first one is also called the big toe, or the Hallux.
 THE BONES OF THE UPPER LIMB
(Ossa membri superioris)

The skeleton of the upper limb it composed of:

- the bones of the shoulder girdle formed by clavicle and scapula.
- the bones of the free part of upper limb, consisting of three segments:
- the skeleton of the arm(Humerus)
- the skeleton of the forearm(Ulna and Radius)
- the skeleton of the hand; composed of carpal bones, metacarpal bones, and phalanges

THE BONES OF THE PECTORAL GRIDLE

(Ossa cinguli membri superioris)

They serve to connect the bones of the free part of upper limb to the ribcage.

CLAVICLE
(Clavicula)

Position: It is situated in the anterior-superior part of the thorax; has the shape of the
letter “S”, transversely oriented between sternal manubrium and acromion.
Parts: It presents a body, two ends, and two curvatures.
Medial or sternal end (Extremitas sternalis) is voluminous, prismatic, triangular,and
has a sternal articular surface (Facies articularis sternalis).
The body (Corpus) “S” shaped, has a medial curvature (convex anteriorly, and larger),
and another lateral curvature(concave, and shorter); it has two surfaces and two borders:
Superior surface (Facies superior); it is smooth.
Inferior surface (Facies inferior) oriented toward the first rib and presents:
- Subclavian groove (Sulcus musculi subclavi); a longitudinal groove situated in the
middle of the body;
- Impression for costoclavicular ligament(Impressioligamenti
costoclavicularis);appears as a rough patch situated medially from the subclavian groove;
- Two rough prominences are found laterally from the subclavian groove: conoid
tubercle (tuberculum conoideum); round, and oriented posteriorly. The trapezoid line
(Linea trapezoidea); situated anterior-lateral from the tubercle.
Anterior border; it is convex in the medial third, and concave in the lateral third.
Posterior border; it is convex-concave opposite to the anterior border.
Lateral, or acromial end (Extremitas acromialis), is flattened from top to bottom,
presents an oval articular surface which is smooth (Facies articularis acromialis) which
articulates with the scapula.

SCAPULA
(Scapula)

Position: Scapula, or shoulder blade,is a flat bone, triangular with the base upwards,
situated in the posterior-superior part of the thorax.
Parts: It has two surfaces, three borders, and three angles.
Dorsal surface (Facies dorsalis) is oriented postero-laterally, and presents:
- Scapular spine (Spina scapulae); the bone blade;it is triangular, flattened from top
to bottom, and situated in the upper portion of the surface. It is oriented obliquely, in a
superior-lateral direction. It has a summit, two surfaces, and a border;
 - The summit (Acromion) is the free terminal part of the scapular spine. It is flattened
from top to bottom, and orientedanteriorly. It has an oval articular face for the clavicle
(Facies articularis clavicularis) which is smooth above the spine:
- above the scapular spine there is a hollow area called the supraspinatous fossa
(Fossa supraspinata)
- infraspinatous fossa (Fossa infraspinata) is a large triangular depression situated
under scapular spine.
Costal surface (Facies costalis), or anterior surface, is concave (Fossa
subscapularis), andpresents several oblique ridges for the insertion of subscapularis muscle.
Borders:
- Superior border (Margo superior); it is thin, and presents a small notch, called
scapular notch (Incisura scapulae), which situated on the lateral side of this border; this
notch is converted into a foramen by a ligament (Ligamentum transversum scapulae);
- Medial or vertebral border (Margo medialis); is a ridge oriented vertically, parallel
with the vertebral column;
- Lateral or axillary border (Margo lateralis); it is oblique, and oriented toward
axilla.
Angles:
- Superior angle (Angulus superior); rectangular, situated between the superior and
medial borders of the scapula;
- Inferior angle (Angulus inferior); sharp, situated between the medial and lateral
borders of the scapula;
- Lateral angle (Angulus lateralis); voluminous, situated between the superior and the
lateral borders of the scapula, it presents:
- Glenoid cavity (Cavitas glenoidalis); an oval articular surface. It is excavated, and
smooth, and it articulates with the humerus;
- Supraglenoid tubercle (Tuberculum supraglenoidale); it is a rounded, rough
prominence;
- Infraglenoid tubercle (Tuberculum infraglenoidale); rough prominence;
- Anatomical neck of scapula (Collum scapulae); it isa narrow bone segment,
situated medially from the glenoid cavity;
- Coracoid process (Processus coracoideus); it is a boney extension, curved
anteriorly, and is situated between glenoid cavity and the hollow of scapula.
 BONES OF THE FREE PART OF UPPER LIMB
(Ossa membri superioris liberi)

ARM SKELETON
HUMERUS
(Humerus)

Position: It forms the boney skeleton of the arm.

Parts: Long bone, consisting of two extremities and a body.
Upper, or proximal extremity(epiphysis) of humerus; it is the larger of the two
extremities, and presents:
- Humeral head (Caput humeri); it is an articular surface, smooth, formed from a
third of a sphere; it is directed medially, upward, and a little backward. The axis through the
head of the humerus, and and the axis through the body of the humerus are forming an angle
of about 130o.
- Anatomical neck (Collum anatomicum) is a circumferential groove that separates
the head from the rest of the upper extremity.
- Greater tubercle (Tuberculum majus) is a voluminous tuberosity, situated on the
lateral side of the extremity. It presents three rough surfaces for muscular insertions.
- Lesser tubercle (Tuberculum minus), this rounded rough prominence, is situated
medially from the greater tubercle.
- The two tubercles continue at the level of the humeral body as the crest of the
greater tubercle (Crista tuberculi majoris), and the crest of the lesser tubercle (Crista
tuberculi minoris); the two crests delimit a vertical groove named the intertubercular groove
(Sulcus intertubercularis) that is situated anteriorly.
- Surgical neck (Collum chirurgicum) is a narrow cylindrical segment, situated
between the upper extremity and the body of humerus. It is a common site for fractures.
The body of humerus (Corpus humeri), or shaft of the humerus; in the upper part it
iscylindrical, and in the lower part it is triangular/prismatic. It has three borders, and three
surfaces;
- Antero-medial surface (Facies anterior medialis) is smooth, and presents the
inferior part of the intertubercular groove in its upper third. The nutritive foramen (Foramen
nutricium) of the bone can also be found in its middle third.
- Antero-lateral surface (Facies anterior lateralis) presents the “V” shaped deltoid
tuberosity (Tuberositas deltoidea) in its upper third; in the inferior part, one finds an oblique
groove for the radial nerve (Sulcus nervi radialis).
- Posterior surface (Facies posterior) is smooth. Beginning from the lateral side, it is
crossed by the continuation of the radial groove (Sulcus nervi radialis) in an oblique
anterior-posterior direction.
Borders:
- Anterior border (Margo anterior) separates the antero-medial from the antero-
lateral surface. The upper part is more pronounced, and conflates with the crest of the greater
tubercle.
- Medial border (Margo medialis) separates the antero-medial surface from the
posterior surface, and is more pronounced in the lower half.
- Lateral border (Margo lateralis) is more obvious in the lower half of the shaft.
Lower, or distal extremity(epiphysis) of humerus, is flattened and curved from
posterior to anterior. It has a larger transverse diameter bigger in the form of a palette. It has a
condyle, and two epicondyles:
- Humeral condyle (Condylus humeri) has two articular surfaces and three fossae.
 - Trochlea (Trochlea humeri) has the shape of a pulley, is transversly oriented with
two slopes and a spiroid vertical groove. This is oriented from medial to lateral, and
establishes a direct contact with trochlear notch from ulna;
- Capitulum (Capitulum humeri), is a round prominence, smooth, and situated
laterally from trochlea;
- Coronoid fossa (Fossa coronoidea); a depression situated on the anterior surface of
humeral condyle, above the trochlea;
- Radial fossa (Fossa radialis); it is situated above capitulum and laterally from
coronoid fossa;
- Olecranon fossa (Fossa olecrani), is deeper, placed on the posterior surface of
condyle, above trochlea, ensures the penetration of olecranon.
- Epicondyles; two prominences, in the continuation of medial and lateral borders of
humeral body, above humeral condyle:
- Medial epicondyle (Epicondylus medialis) is a prominence that on the postero-
inferior surface has the groove for the ulnar nerve (Sulcus nervi ulnaris) with avertical
orientation;
- Lateral epicondyle (Epicondylus lateralis) is a prominence that is smaller than
medial epicondyle.
 FOREARM SKELETON

It’s composed of two parallel long bones: ulna and radius.

ULNA
(Ulna)

Position: The medial side of the forearm.

Parts:It is a long bone with two extremities and a body.
Upper extremity or epiphysis; more voluminous, it presents:
- Olecranon (Olecranon); large apophysis, oriented vertically, has two surfaces and a
summit;
- Anterior surface, concave, smooth, articular;
- Posterior surfaces, convex, rough;
- The summit, curved anteriorly, corresponds to olecranon fossa;
- Coronoid process (Processus coronoideus), oriented transversely with the summit
directed anteriorly;
- Trochlear notch (Incisura trochlearis) – is a smooth surface, articular, oriented
anteriorly, and delimited by the olecranon and the coronoid process; it corresponds to
humeral trochlea;
- Radial notch (Incisura radialis), is a articular semilunar notch, situated on the
lateral surface of coronoid process, comes in contact with the articular circumference of
radius head.
- Ulnar tuberosity (Tuberositas ulnae) is a larger rugosity placed under the coronoid
process;
Body of ulna (Corpus ulnae); it is a prismatic, triangular and, concave on its anterior
surface in its proximal part. It is rounded and narrower distally. It has three surfaces and three
borders:
- Anterior surface (Facies anterior) concave and smooth;
- Posterior surface (Facies posterior) presents rugosities and ridges for muscular
insertions;
- Medial surface (Facies medialis); large in its proximal side, and narrow distally. It
is palpable under the skin;
Borders:
- Anterior border (Margo anterior) stretches from the coronoid process to the styloid
process, between the anterior and medial surfaces;
- Posterior border (Margo posterior); it is situated between the medial and posterior
surfaces, like a sinuous ridge that stretches up to the lower third of the shaft. It protrudes
under the skin;
- Lateral or interosseous border (Margo interosseus) it is sharp in the upper segment,
and is facing towards the radius. Between the two, there is delineated an interosseous, elliptic
space (Spatium interosseum antebrachii).
Lower (distal) extremity or epiphysis, narrower, it presents:
- Head of ulna (Caput ulnae); a cylindrical segment, with a smooth circular articular
surface (Circumferentia articularis), that articulates with radial ulnar notch.
- Styloid process (Processus styloideus); it is the medial extension of the head. It has
a conoid shape with the summit facing downwards.
 RADIUS
(Radius)

Position: lateral side of the forearm.

Parts: Long bone, with two extremities, and a body.
Upper (proximal) extremity or epiphysis presents:
- Head of radius (Caput radii); it has the form of a cylindrical segment, and it
presents:
- Articular facet of head of radius (Fovea capitis radii); a smooth depression on the
superior surface that articulates with capitulum of the humerus;
- Articular circumference (Circumferentia articularis); a circular surface, smooth,
and corresponds to radial notch from ulna;
- Neck (Collum radii); it is narrow, cylindrical, and situated between the head and the
body of the bone with an oblique downward and medial trajectory.
- Radial tuberosity (Tuberositas radii); it is a rough prominence, ovoid, and situated
anteriorly between the neck and the shaft. The biceps brachii muscle inserts on it.
Body (Corpus radii); prismatic, and triangular in shape. It presents three surfaces,
and three borders:
- Anterior surface (Facies anterior) is excavated, and narrow in its proximal part. It
widens distally, and is oriented anteriorly and medially.
- Posterior surface (Facies posterior) is rounded proximally, and is flat and excavated
distally;
- Lateral surface (Facies lateralis) is rounded, and on its middle third, it has an area
of increased rugosity (Tuberositas pronatoria) for the insertion of pronator teres muscle.
- Anterior border (Margo anterior); it stretches from the radial tuberosity to the
inferior third of the shaft between the anterior and lateral surfaces;
- Posterior border (Margo posterior); it is situated between the posterior and lateral
surfaces of the shaft, and is more pronounced in its middle third;
- Medial or interosseous border (Margo interosseus); it is sharp, and found between
the anterior and posterior surfaces, oriented toward ulna. It delimitates the interosseous space
of the forearm.
Lower (distal) extremity or epiphysis, is voluminous, and with the form of a truncated
pyramid that presents:
- Anterior surface; concave, smooth;
- Posterior surface; convex, crossed by ridges and oblique, vertical grooves;
- Medial surface; has a transversal smooth excavation, the ulnar notch (Incisura
ulnaris) for the head of ulna;
- Lateral surface;pyramid shaped, with the summit directed distally, and represented
by styloid process (Processus styloideus);
- Inferior surface; the base or the inferior surface of the pyramid. It is smooth,
concave, and extends laterally toward the styloid process. It presents an articular surface
(Facies articularis carpalis) for the articulation with the carpal bones (scaphoid and lunate
bones).
 HAND BONES
(Ossa manus)

The skeleton of the hand is composed of three distinct parts:

- Carpal bones (Ossa carpi)
- Metacarpal bones (Ossa metacarpalia)
- Finger bones (Ossa digitorum manus)

CARPAL BONES
(Ossa carpi)

They are small bones, irregular, and juxtaposed upon each other. A total of 8 bones,
situated at the wrist, are placed in two rows: proximal and distal.

Proximal(superior) row:
- Scaphoid bone (Os scaphoideum)
- Lunate bone (Os lunatum)
- Pyramidal bone (Os triquetrum)
- Pisiform bone (Os pisiforme)

Distal(inferior) row:
- Trapezium bone (Os trapezium)
- Trapezoid bone (Os trapezoideum)
- Capitate bone (Os capitatum)
- Hamate bone (Os hamatum)

The 8 bones are forming the carpus (Carpus) presenting:

The dorsal surface; convex transversally, rough, and irregular;
The palmar(anterior) surface; concave, and forms an elongated groove (Sulcus carpi)
delimited by two prominences:
- Lateral eminence (Eminentia carpi lateralis); it formed by the tubercle of scaphoid
bone and the tubercle of trapezium bone.
- Medial eminence (Eminentia carpi medialis); it is formed by the pisiform bone and
the hook of hamate bone.
- Lateral borders are narrow.

SCAPHOID BONE
(Os scaphoideum)

Position: It is situated in the lateral part of the proximal row of the carpus; it has the
shape of a boat.
Surfaces:
- Superior surface; large, convex, smooth, and articulates with radius.
- Inferior surface; convex, smooth, and articulates with trapezium and trapezoid
bones.
- Medial surface; smooth, and is divided by a ridge in two articular surfaces: superior-
medial for the lunatum bone, and inferior-medial for the head of capitate bone.
- Palmar (anterior) surface presents a tubercle (Tuberculum ossis scaphoidei).
 LUNATE BONE
(Os lunatum)

Position: Situated in the proximal row, between the scaphoid bone and the pyramidal
bone has a semilunar shape.
Surfaces:
- Superior surface; large, convex, smooth, and articulates with radius
- Inferior surface; it is deeply concave for the articulation with the capitate and hamate
bones.
- Medial surface; smooth, quadrilateral, and articulates with the pyramid bone;
- Lateral surface; smooth, flat, and meets the scaphoid bone;
- Palmar surface; rough;
- Dorsal surface; rough;

PYRAMIDAL BONE
(Os triquetrum)

Position: It has a pyramidal shape, is obliquely oriented, and transverse. The base is
oriented laterally, and with the summit medially. It is situated between the lunate bone, and
hamate bone.
Surfaces:
- Superior surface; smooth, convex, and oriented towards the head of ulna.
- Inferior surface; sinuous, quadrilateral, smooth, and articulates with the hamate
bone.
- Lateral surface; corresponds to the pyramid base, quadrilateral, smooth, and
articulates with the lunate bone.
- Palmar surface; presents an articular surface, flat, circular, and round for the
pisiform bone.

PISIFORM BONE
(Os pisiforme)

Position: Oval shaped, is situated on the palmar surface of the pyramidal bone.
Surfaces:
- Basal surface; it is oval or circular, smooth, articulates with the pyramidal bone.

TRAPEZIUM BONE
(Os trapezium)

Position: It is situated on the lateral side of the distal row of carpus and has a cubic
form, irregular.
Surfaces:
- Superior surface; concave, smooth, and articulates with scaphoid bone;
- Inferior surface; concave, saddle shaped, smooth. It is oriented distally, laterally and
anteriorly. It articulates with the base of the first metacarpal bone;
- Medial surface; smooth, and it presents two articular surfaces: a larger superior one
that comes in contact with trapezoid bone, and the inferior one, which is smaller, andis in
contact with the basis of the second metacarpal bone;
- Lateral surface – narrow, rough;
 - Palmar surface; presents a rough prominence, the tubercle of trapezium
(Tuberculum ossis trapezi), which is medially flanked by a groove;
- Dorsal surface; rough.

TRAPEZOID BONE
(Os trapezoideum)

Position: Small, irregular, cube shaped bone. It is situated between the trapezium
bone and capitate bone.
Surfaces:
- Superior surface; concave, smooth, and comes in contact with scaphoid bone.
- Inferior surface; reniform, smooth, and articulates with the base of the second
metacarpal bone.
- Medial surface; concave, smooth, elongated, and comes in contact with the capitate
bone.
- Lateral surface; convex, smooth, and comes in contact with trapezium bone.
- Palmar surface; small, and rough.
- Posterior surface; more extended, rough, and convex.

CAPITATE BONE
(Os capitatum)

Position: The most voluminous carpal bone, occupies the center of the wrist.
Parts:
- Head (Caput); round, smooth, and comes in contact with the indentation made by
the scaphoid and lunate bones.
- Neck (Collum); narrower segment, and rough.
- Body (Corpus); broader, pyramid shaped, and with the base toward metacarpal
bones.
Surfaces:
- Superior surface; belongs to the head. It is round, smooth, and articulates with the
scaphoid and lunate bones.
- Inferior surface; it presents three articular surfaces, delimited by ridges, and comes
in contact with the base of the metacarpals II-III-IV.
- Medial surface; smooth, elongated, and articulates with hamate bone.
- Lateral surface; smooth, elongated, and articulates with trapezoid bone.
- Palmar surface; rough.
- Dorsal surface; flat, rough, and broader.

HAMATE BONE
(Os hamatum)

Position: It is situated in the medial side of the distal row of the carpus. It has the
shape of a feather(pyramid), and stuck between the capitate bone and the pyramidal bone.It
has its peak pointed supero-medially towards the lunate bone. The broader base is pointed
towards the fourth and fifth metacarpal bones.
Surfaces:
- Medial surface; smooth, sinuous, and articulates with the pyramidal bone;
- Inferior surface; presents two articular surfaces, which are divided by a ridge, for the
basis of metacarpal bones IV and V.
 - Lateral surface; elongated, smooth, flat, and articulates with the capitate bone;
- Palmar surface; presents a laterally curved hook-shaped process, (Hamulus ossis
hamati)
- Dorsal surface is rough, and flat.

METACARPAL BONES
(Ossa metacarpalia I-V)

Position: They form the skeleton of the palm. There are five long bones, that together
form the metacarpus (Metacarpus). They are numbered from lateral to medial, with Roman
numerals, from I to V.
Parts:
- Base (Basis) or proximal extremity; it is broader transversally, and presentsmore
articular surfaces destined to articulate to adjacent carpal and metacarpal bones.
- Body (Corpus); prismatic, triangular, and presents three surfaces: dorsal, anterior-
medial, and lateral. Also, it presents three borders. The anterior border is like a concave
boney ridge. The body is curved toward palmar surface.
- Head (Caput); flattened transversely towards the palmar surface, and has a convex
articular surface for the proximal phalanx.
Particular features of the metacarpals:
- First metacarpal bone is short, broader at the base, and proximally presents a saddle-
shaped articular surface for the trapezium bone;
- Second metacarpal bone;it is the longest of the metacarpal bones. It has a forked
base which articulates with trapezium bone, trapezoid bone and capitate bone, and medially,
it articulates with third metacarpal bone;
- Third metacarpal bone; it has a styloid process (Processus styloideus) oriented
laterally, and it articulates with the capitate bone,the second, and the fourth metacarpal bones;
- Fourth metacarpal bone; it has a quadrilateral base, and articulates with the capitate
bone, the hamate bone, and with third and fifth metacarpal bones;
- Fifth metacarpal bone; the base articulates on some small surfaces with hamate
bone, and with fourth metacarpal bone.

FINGER BONES
(Ossa digitorum manus)

Position: They form the fingers skeleton. There are three phalanges (Phalanx) for
each finger; except the thumb, which has only two phalanges. All of them are short bones.
Parts:
- Base (Basis phalangis);
- Body (Corpus phalangis);
- Head (Caput phalangis);
Proximal phalange (Phalanx proximalis) is a long bone and presents:
- Base (Basis phalangis); it has a concave articular cavity,large, and it articulates with
the head of the metacarpal bone.
- Body (Corpus phalangis); it is flattened from anterior to posterior, and has a
convex dorsal surface.
- Head (Caput phalangis); it has a trochlear-shaped articular surface for the middle
phalange.
Middle phalange (Phalanx media) presents:
 - Base (Basis phalangis); it has a concave articular surface for the head of the
proximal phalange.
- Body (Corpus phalangis); short, semi-cylindrical, and with the dorsal surface
slightly convex.
- Head (Caput phalangis); it has a trochlear-shaped articular surface for the distal
phalange.
Distal phalange (Phalanx distalis) presents:
- Base (Basis phalangis); it has a concave articular surface for the head of the middle
phalange.
- Body (Corpus phalangis); very short.
- Head (Caput phalangis); broader, rough, and semilunar shaped (Tuberositas
phalangis distalis) that corresponds to the nail.

SESAMOID BONES
(Ossa sesamoidea)

Position: Small lenticular bones which are situated in the tendons, or ligaments, on
the palmar surface at the level of metacarpophalangeal joint. There are two for the thumb,
and one for the second and fifth fingers.
 THE BONES OF THE INFERIOR LIMB
(Ossa membri inferioris)

The skeleton of the inferior limb is made up of:

- The bones of the pelvic girdle – the two coxal bones
- The bones of the free inferior limb, which consists of three segments:
- The thigh: femur
- The calf: tibia (also known as the shinbone or shankbone) and the fibula (or the calf
bone)
- The foot:
- The tarsal bones
- The metatarsal bones
- The phalanges

THE BONES OF THE PELVIC GRIDLE

(Ossa cinguli membri inferioris)

THE ILIUM BONE

(Os ilium)

Position: situated in the superior part of the os coxae

Parts:
The body of the ilium bone (Corpus ossis ilii) is the narrow part of the bone; together
with the pubis and the ischium bone, it forms the acetabulum, or the cotyloid cavity
(Acetabulum).
The wing of the illium (Ala ossis ilii) is a flat, wing-shaped part of the ilium bone. It
has three faces and three margins:
- The internal face of the bone (Fossa iliaca) is concave and smooth, and is situated
on the antero-medial aspect of the bone, between the iliac crest and the arcuate line (Linea
arcuata) – a bony landmark with an oblique trajectory (from supero-medial to infero-lateral)
which separates the ilium from the pubis and the ischium.
- The external face or gluteal face of the bone (Facies glutea) is convex, is situated on
the postero-lateral aspect, and has the following landmarks:
- The anterior gluteal line (Linea glutea anterior) which has a curved trajectory from
superior to postero-inferior between the iliac crest and the inferior gluteal line
- The posterior gluteal line (Linea glutea posterior) is situated posterior from the
previous line, and has a vertical trajectory
- The inferior gluteal line (Linea glutea inferior) is situated above the superior part
of the rim of the acetabulm
- The sacro-pelvic face (Facies sacropelvica), on the postero-medial aspect of the
bone, between the external and internal faces of the bone, presents:
- The auricular face (Facies auricularis) – a rough bony surface resembling an ear
lobe; it corresponds to the auricular face of the sacral bone.
- The iliac tuberosity (Tuberositas iliaca) is rough, and has a wide surface. It is
situated supero-posteriorly from the auricular face. It serves as an insertion point of the
ligaments.
The superior margin, the iliac crest (Crista iliaca) has a S-shaped curved trajectory
and presents:
- The internal lip (Labium internum)
- The external lip (Labium externum)
 - The intermediate line (Linea intermedia) is a bony crest situated between the two
lips.
At the anterior and posterior extremity of the crest, the three lines join to form an
antero-superior and a postero-superior spine (Spina iliaca anterior superior et Spina iliaca
posterior superior)
The anterior margin, which is concave on the anterior side, is also named the
innominate notch, and is situated between the antero-superior iliac spine and the antero-
inferior iliac spine (Spina iliaca anterior inferior).
The posterior margin is a short, sharp, concave margin, positioned between the
postero-superior iliac spine and the postero-inferior iliac spine (Spina iliaca posterior
inferior).

THE ISCHIUM BONE

(Os ischii)

Position: postero-inferior part of the coxal bone

Parts:
- The body (Corpus ossis ischii) – an irregular bone which is part of the acetabulum,
the cotyloid cavity
- The ramus (Ramus ossis ischii) – a flat bony segment, curved anteriorly, with a
sharper anterior margin and a blunter posterior margin. It welds together with the inferior
ramus of the pubis and it presents:
- The ischial spine (Spina ossis ischii) has a triangular prismatic shape which directs
medially and posteriorly.
- The greater sciatic notch (Incisura ischiadica major) – a smooth rounded margin,
placed between the ischial spine and the postero-inferior iliac spine.
- The lesser sciatic notch (Incisura ischiadica minor) is situated between the ischial
spine and the tuberosity of the ischium.
- The tuberosity of the ischium (Tuber ischiadicum) isa rough, wide, oval-shaped
bony bulge. It is placed on the postero-inferior margin of the ramus at the limit between the
body and the ramus.

THE PUBIC BONE

(Os pubis)

Position: Antero-inferior part of the coxal bone

Parts:
The body (Corpus ossis pubis) forms the antero-inferior part of the acetabulum
The two branches of the pubic bone (Ramii ossis pubis), together with the ramus of
the ischium, delimit the obturator foramen (Foramen obturatum)
The superior ramus (Ramus superior ossis pubis) – an antero-medial, prismatic,
triangular continuation of the body. It presents:
- The iliopubic eminence (Eminentia ilio-pubica or ilio-pectinea) is a smooth
prominence that is situated laterally from the linea arcuata at the limit between the pubic bone
and the illium.
- The pectineal line (Crista pubica or Pecten ossis pubis) is a rough, linear
prominence that is situated on the superior margin of the ramus, and lies in continuation of
the arcuate line.
- The pubic tubercle (Tuberculum pubicum) is a small, rough bulge that is found in
the continuation of the pectineal line.
 - The obturator groove (Sulcus obturatorius) is placed on the inferior aspect of the
ramus, and opens towards the obturator foramen. It delimits the superior side of the obturator
canal.
- The symphyseal surface (Facies symphysialis) is a rough oval shaped surface, with
the long axis situated vertically. It is found on the internal aspect of the pubic angle.
The inferior ramus (Ramus inferior ossis pubis) is positioned between the pubic
angle and the ramus of the ischium.
The acetabulum, or the cotyloid cavity (Acetabulum), is a wide cavity formed from
the merging of the lateral sides of the bodies of the three parts of the coxal bone (ilium,
ischium and pubis). It is orientated antero-laterally and inferiorly. It has a spherical shape and
it articulates with the femoral head. It presents:
- The lunate surface (Facies lunata); a smooth surface, situated in the peripheral part
of the acetabular fossa; it articulates with the femoral head.
- The acetabular fossa (Fossa acetabuli) is a rough depression in the profound area of
the acetabulum.
- The acetabular rim (Limbus acetabuli or Margo acetabuli) is a circular bony
prominence that surrounds the acetabulum. In the inferior part, it is interrupted by a deep and
large notch, called the acetabular notch (Incisura acetabuli).
The obturator foramen is a large holedelimitd by the rami of the ischium and pubic
bone. It is closed by the obturator membrane (Membrana obturatoria). The internal
circumference of the foramen is interrupted underneath the superior ramus of the pubic bone
by a groove that is orientated anterior and medially, called the obturator groove (Sulcus
obturatorius). This groove is transformed by the obturator membrane into a canal (Canalis
obturatorius).
 THE BONES OF THE FREE INFERIOR LIMB
(Ossa membri inferioris liberi)

THE BONES OF THE THIGH

THE FEMUR
(Femur)

Position: It forms the axial skeleton of the thigh, and is the longest bone of the body.
Parts:
It presents 2 extremities and a shaft.
The superior (proximal) extremity is formed by the head (Caput femoris), neck
(Collum femoris), and the two trochanters (Trochanter major and minor).
- The femoral head is a surface which represents 2/3 of a sphere, smooth articulated
with a small rough depression (Fovea capitis femoris)
- The neck is placed between the head and the shaft of the femur. It is flattened
antero-posteriorly, and has an oblique direction that stretches from the supero-medial towards
the infero-lateral. The collum forms an angle with the shaft of 125-130 degrees. This angle is
called the flexion, or the inclination angle. The neck is orientated from the plane of the body
anteriorly, and is forming an angle of approximately 12 degrees. This angle is called the
declination, or the anteversion angle.
- The greater trochanter (Trochanter major) has a rough quadrangular prominent
surface that is situated laterally. It presents on its medial aspect a rough depression. (Fossa
trochanterica)
- The lesser trochanter (Trochanter minor) is a rough coned-shaped prominence that
is situated at the limit between the neck and the shaft, with a postero-medialorientation.
- The two trochanters are united anteriorly by a linear bony crest, the intertrochanteric
line (Linea intertrochanterica). This an oblique line between the two trochanters. The
trochanters are also united posteriorly by the intertrochanteric crest (Crista
intertrochanterica).
The femoral shaft (Corpus femoris) is cylindrical in its proximal part, and flatter in
its distal part. It presents a slight curve anteriorly with:
- Anterior convex aspect, smooth, with faded margins
- Posterior concave aspect, presenting:
- The linea aspera(Linea aspera) – a rough prominence with two ridges: internal
ridge (Labium mediale) and external ridge (Labium laterale). The two ridges are divergent
in the proximal and distal parts of the bone.
- The gluteal tuberosity (Tuberositas gluteae) – a very rough prominence which
continues the lateral ridge of the linea aspera towards the base of the greater trochanter. If it
has a more pronounced character it is called the third trochanter (Trochanter tertius).
- The pectineal crest (Linea pectinea) – a bony line proximal to the medial ridge of
the linea aspera; it is orientated towards the lesser trochanter.
- The popliteal surface (Facies poplitea) – a triangular-shaped smooth surface that is
situated in the inferior part of the bone between the two ridges of the linea aspera.
The inferior extremity, or the distal epiphysis, is voluminous, wide, and has a longer
transversal diameter. Distally, it ends with two asymmetrical prominences that are divergent
in the posterior side – the medial and lateral condyles (Condylus medialis et lateralis).
- The medial condyle (Condylus medialis); the infero-medial extension of the
extremity is longer and narrower than the lateral one (Condylus lateralis).
 - The articular surfaces (Facies articularis) are curved antero-posteriorly, and by
their merger, the patellar surface is formed (Facies patellaris) on the anterior aspect of the
extremity.
- The medial facets (Facies medialis) are rough, and they’re divided by a deep notch,
the intercondylar fossa (Fossa intercondylaris), which is delimited towards the popliteal
surface by the intercondylar line (Linea intercondylaris).
- The lateral surfaces are rough and present on the superior parts a prominence; the
medial and lateral epicondyles (Epicondylus medialis et lateralis). On the medial
epicondyle, a small, rough tubercle is found, called the adductor tubercle (Tuberculum
adductorium). This serves for the insertion of a tendinous fascicle of the adductor magnus
muscle.

PATELLA
(Patella)

Position: the anterior part of the knee, anterior from the patellar surface of the femur,
inside the tendon of the quadriceps femoris muscle.
Parts: a short, triangular bone, flattened antero-posteriorly, it presents:
- The basis (Basis patellae) – rough, facing upwards.
- The tip (Apex patellae) – facing downward.
- The two surfaces:
- Anterior (Facies anterior) – convex, rough
- The articular surface (Facies articularis) – smooth, and situated on the
posterior aspect. The latter is divided by a vertical crest into two facets. The lateral one has a
larger surface. It articulates with the patellar aspect of the femur.
- Two margins (Margo patellae) – a lateral and a medial border orientated obliquely
and inferiorly.
 THE SKELETON OF THE LEG

It is represented by two bones, united at their extremities, delimitating an interosseus

gap.

TIBIA
(Tibia)

Position: the medial part of the leg.

Parts: a long bone, with a vertical direction, it has two extremities and a shaft.
The superior extremity is voluminous, wider transversally, and it presents two
condyles – the medial and lateral condyles (Condylus medialis et lateralis).
- The superior articular surface or the tibial plateau is made from two smooth facets,
which correspond to the femoral condyles. The medial facet is oval and deeper than the
lateral facet, which is wider transversally.
- The intercondylar eminence (Eminentia intercondylaris) is a prominence situated
between the two superior articular facets. It ends with two intercondylar tubercles
(Tuberculum intercondylare mediale et laterale) that aredelimitd by a small notch.
The anterior and posterior intercondylar areas (Area intercondylaris anterior et
posterior) are two rough, irregular, triangular surfaces which serve for the insertion of the
articular ligaments of the knee.
- The tibial tuberosity (Tuberositas tibiae) is found on the anterior part of the
extremity.
- The fibular articular facet (Facies articularis fibularis) is situated on the lateral
aspect of the lateral condyle.
The shaft (Corpus tibiae) is triangular, prismatic, and has three surfaces and three
margins:
- The medial surface (Facies medialis), is plane, smooth, and can easily be palpated
subcutaneously.
- The lateral surface (Facies lateralis) is smooth, situated distally, with an antero-
lateral orientation.
- The posterior surface (Facies posterior) is wide proximally and becomes narrower
distally.
- The soleal line (Linea musculi solei) is an oblique line that is orientated inferiorly
and medially in the superior part of the tibial shaft.
- The anterior margin (Margo anterior) is sharp, and is situated between the medial
and lateral aspects of the shaft. It has an elongated, italic “S” shape. Proximally, it ends under
the tibial tuberosity, and distally, it ends on the medial malleolus.
- The medial margin (Margo medialis) is more pronounced in the distal part.
- The interosseus margin (Margo interosseus), or the lateral margin, participates at
the delimitation of the interosseus gap of the leg. It is bifurcated in the inferior part of the leg
to delimit the fibular notch.
The inferior extremity is cuboid and irregular:
- The medial malleolus (Malleolus medialis) – the medial extension of the bone is
flattened transversally with the articular surface (Facies articularis malleoli) orientated
laterally. On its posterior aspect, a vertical groove can be found (Sulcus malleolaris).
- The inferior articular surface (Facies articularis inferior) is smooth, and concave
antero-posteriorly. In the medial part, it continues with the articular surface of the medial
malleolus.
 - The fibular notch (Incisura fibularis) is situated on the lateral aspect of the
extremity and it articulates with the fibula.

FIBULA
(Fibula)

Position: the lateral part of the leg.

Parts: A long bone, orientated vertically, it has two extremities and a shaft.
The superior extremity presents:
- The head of the fibula (Caput fibulae) is rough, conical, and, on its medial side, it
presents a smooth, oval surface (Facies articularis capitis fibulae) for the articulation with
the tibia.
- The tip (Apex capitis fibulae) is a sharp extension situated in the superior part of
the head.
The shaft (Corpus fibulae) is thin and it presents three surfaces and three margins:
- The medial surface (Facies medialis) presents an oblique longitudinal crest (Crista
medialis).
- The lateral surface (Facies lateralis)
- The posterior surface (Facies posterior) distally, it blends with the medial aspect of
the diaphysis.
- Magins:
- Anterior (Margo anterior).
- Posterior (Margo posterior).
- Interosseus (Margo interosseus) is orientated medially towards the tibia. It is more
pronounced in the middle part of the diaphysis, and represents the lateral limit of the
interosseus gap of the leg.
The inferior extremity presents:
- The lateral malleolus (Malleolus lateralis), a rough, flattened transversally
prominence, which is longer and more voluminous than the medial one. Inferiorly, it ends
with a tip.
- The articular surface of the malleolus (Facies articularis malleoli) is situated in the
anterior part of the medial surface for the articulation with the talus bone.
- The fossa of the lateral malleolus (Fossa malleoli lateralis) a deep notch placed
posterior from the articular surface.
- A longitudinal groove for the passage of the tendons of the fibular muscles (Sulcus
malleolaris).
 THE BONES OF THE FOOT

THE TARSAL BONES

(Ossa tarsi)

The tarsal bones counting as far as 7 build up the tarsus and are grouped in 2 rows:
-the posterior row (proximal) composed by the talus, and beneath it, the calcaneus.
-the anterior row (distal) made of the navicular, cuboid, and the three cuneiform
bones.

TALUS
Talus

Position: located between the fibula, tibia, calcaneus and navicular bones.
Parts: head, neck and body; has a cuboid shape.
The head (Caput tali), is a proeminence stretched transversally with an anteriorly
convex, oval-shaped articular surface for the navicular bone (Facies articularis navicularis).
The neck (Collum tali) lies inferior and medial connecting the head with the body.The body
of the talus (Corpus tali) makes the most out of the surface of the talus with the following
elements:
- Trochlea talihave the form of a pulley with 3 articular surfaces: superior, medial
and lateral which articulate with the tibia and fibula.
- The superior surface has a wide, smooth articular surface (Facies articularis
superior) for the tibia.
- The medial surface has a smooth, semicolon-shaped articular surface (Facies
malleolaris medialis) for the tibia.
- The lateral face has a triangular articular surface (Facies malleolaris lateralis) for
the fibula.
- Processus lateralis taliis triangular, and is located under Facies malleolaris
lateralis to serve as a mechanical support for the lateral malleolus.
- The inferior surface hosts three articular facets which connect the talus with the
calcaneus:
-Facies articularis calcanea anterior (on the inferior aspect of the head)
-Facies articularis calcanea media (between the neck and the body)
-Facies articularis calcanea posterior (on top of the body)
-Sulcus tali (between Facies articularis calcanea posterior and media)
- The posterior surface contains Processus posterior talithatcrossed by Sulcus
tendinis musculi flexoris hallucis longi, and isbordered medially and laterally by
Tuberculum mediale et laterale.

CALCANEUS
(Calcaneum)

Position: beneath the talus.

Parts: cuboidal shape with six surfaces.
-The anterior surface: articulates with the cuboid bone via Facies articularis
cuboidea
-The superior surface: has three articular surfaces corresponding to the ones from the
inferior part of the talus:
-Facies articularis talaris anterior
 -Facies articularis talaris media
-Facies articularis talaris posterior
-Sulcus calcanei isanoblique groove between the middle and posterior surface of the
talus (both Sulcus calcanei and Sulcus tali form Sinus tarsi)
-The medial surface contains:
-Sustentaculum tali – supports the talus; has a smooth superior surface and
corresponds to the middle articular facet of the talus
-Sulcus tendinis musculi flexoris hallucis longi is found between the
sustentaculum tali and tuberositas calcanea
-The lateral surface contains two structures:
-Trochlea fibularis
-Sulcus tendinis musculi fibularis longi beneath the trochlea fibularis
-The inferior surface is rough and is the inferior extension of tuberositas calcanea
-The posterior surface, also known as Tuber calcanei, serves as insertion site for the
Achillean tendon and has two proeminences: Processus medialis et lateralis tuberis
calcanei.

NAVICULAR BONE
(Os naviculare)

Position: on the medial aspect of the foot between the head of the talus, cuboid bone
and the three cuneiform bones.
Parts: six surfaces
-The anterior surface has three smooth surfaces (separated by two obliques crests)
which articulate with the cuneiform bones
-The posterior surface is concave and articulates with the head of the talus
-The superior surface: convex, rough
-The inferior surface oriented towards the sole of the foot
-The medial surface contains Tuberculum ossi navicularis, which has an inferior
direction
-The lateral surface articulates with the cuboid bone

CUBOID
(Os cuboideum)

Position: lateral aspect of the foot, between the calcaneus, third cuneiform and the 4th
metatarsal bone.
Parts: cuboidal shape with six faces.
-The anterior surface: two smooth articular surfaces separated by a vertical bony crest
to serve as joint for the 4th and 5th metatarsal bones.
-The posterior surface: articulates with the calcaneus.
-The superior surface: rough.
-The inferior surface contains Tuberositas ossis cuboidei and Sulcus tendinis
musculi fibularis longi, a groove located anterior to the tubercle.
-The medial surface has a round, smooth articular facet for the 3rd (lateral) cuneiform.
-The lateral surface is narrow and rough.

MEDIAL CUNEIFORM
(Os cuneiforme mediale)
 Position: located on the medial part of the foot between the 1st metatarsal and
navicular; has six surfaces:
-The anterior surface: smooth, convex, articulates with the 1st metatarsal bone.
-The posterior bone: smooth, concave, articulates with the navicular bone.
-The superior face: sharp and rough.
-The inferior face: wide and rough.
-The medial face: rough.
-The lateral face: concave, presents a triangular articular surface for the middle
cuneiform.

MIDDLE CUNEIFORM
(Os cuneiforme intermedium)

Position: located between the medial and lateral cuneiform with the basis oriented
dorsally and the apex towards the plantar; it has five surfaces:
-The anterior face articulates with the second metatarsal
-The posterior face with a concave articular facet for the navicular bone
-The superior face: wider and rough
-The medial face: triangle shaped articular surface for the 1st (medial) cuneiform
-The lateral face: articulates with the 3rd cuneiform

LATERAL CUNEIFORM
(Os cuneiforme laterale)

Position: between the 3rd metatarsal, navicular, middle cuneiform and cuboid bone;
the basis is dorsally oriented, while the apex oriented towards the plantar; has five aspects:
-The anterior surface: smooth, articulates with the 3rd metatarsal.
-The posterior surface: smooth, articulates with the navicular.
-The superior surface: wider and rough.
-The medial surface: articulates with the middle cuneiform.
-The lateral surface: articulates with the cuboid bone.

METATARSAL BONES
(Ossa metatarsalia)

The five metatarsal bones build up the Metatarsus, and are located between the distal
row of the tarsal bones and the phalanges.
Parts:
-Basis (base), or the proximal extremity, contains three articular surfaces (except for
the proximal part of the 1st metatarsal); it articulates with the tarsal bones and the
neighboring metatarsal bones (medial and lateral).
-Corpus (body)has the form of a prism, a plantar concavity, and three surfaces: dorsal
(smooth and wide), medial, and lateral, which mark the intersosseus spaces.
-Caput (head), or the distal extremity, articulates with the basis of the proximal
phalanx.
The 1st metatarsal bone is short, and voluminous; the basis presents a proximal
concave articular surface for the medial cuneiform and lateral surface for the 2nd metatarsal;
it also contains Tuberositas ossis metatarsalis I.
 - the 2nd metatarsal is the longest. Its basis is articulating with all cuneiform bones,
and it sides articulate with the basis of the 1st and 3rd metatarsals.
-the 3rd metatarsal bone articulates proximally with the lateral cuneiform, and with
the 2nd and 4th metarsal bone laterally.
-the 4th metatarsal bone - the proximal bone presents two articular facets for the
cuboid and lateral cuneiform, while on the sides, the articular surfaces are destined for the 3rd
and 5th metatarsal.
-the 5th metatarsal bone articulates proximally with the cuboid, and medially, with the
4th metatarsal; it contains Tuberositas ossis metatarsalis V.

PHALANGES
(Ossa digitorum pedis)

There are fourteen phalanges; three for each toe (exception: the hallux has two
phalanges).
Position: forms the skeleton of the toes and is numbered from medial to lateral from I
to V.
Parts:
-Basis phalangis – presents an articular surface for the head of the metatarsus
-Corpus phalangis-flattened transversally, concave towards the plantar
-Caput phalangis has the shape of an hourglass.
Types:
-Phalanx proximalis: long, transversally flattened
-Phalanx media: short, having onlya base and a head
-Phalanx distalis: short with a wide nail tuberosity (Tuberositas phalangis distalis)

THE SESAMOID BONES

(Ossa sesamoidea)

The sesamoid bones are small, round, paired structures at the level of the
metacarpophalangeal joints on the plantar aspect of the hallux. They are inconstant in the
joints of the 2nd and 5th phalanx.
 THE BONES OF THE AXIAL SKELETON

THE VERTEBRAS
(Vertebrae)

The spine is a long median and posterior column formed by overlapping 33-34
vertebras.The column is composed of five regions:
- cervical-neck region, is made up of seven vertebras (C1-C7) (Vertebrae
cervicales).
- thoracic - dorsal region, has 12 vertebras corresponding to the thorax (T1-T12). (Vertebrae
thoracicae).
- lumbar region - 5 vertebras forming the posterior wall of the abdominal cavity (L1-L5).
(Vertebrae lumbales).
Vertebras situated in these first three areas (C1-L5) are mobile and independent
(separated by intervertebral discs (Discus intervertebralis)) and belong to true
vertebras(Vertebrae verae) group.
- sacral region - made up of 5 fused vertebras (Os sacruum).
- coccygeal region –consist in 4 / 5 welded vertebras.(Os coccys).
Vertebras situated in these last two parts are welded together and form two bones - the
sacrum and the coccys.Being fused together, they are also called false vertebras(Vertebrae
sprue.
The true vertebras general features:
- A true vertebra has two parts: an anterior region (representing a full cylinder
segment called vertebral body-) and a posterior region (called the vertebral arch-).All these
elements ,the body arch, pedicles, separates the vertebral hole(foramen vertebrale).
The vertebral body (Corpus vertebrae), situated anteriorlly,is the most voluminous
part of the vertebra and has two surfaces: superior and inferior (Facies superior etFacies
inferior).
The anterior segment has a circumference that lies between the two pedicle andthe posterior
part forms the anterior wall of the vertebral oriffice (Foramen vertebrale).
The vertebral arch (Arcus vertebrae)form the lateral and posterior wall of foramen
vertebrale and consists of:
- vertebral pedicles(Pediculus) - are two bridges that connect the vertebral arch with
the vertebral body. The pedicle’ssuperior aspect presents a concavity called Incisura
vertebralis superior, which correspond to a similar notch on the inferior aspect - Incisura
vertebralis inferior. By overlapping two vertebralnotches form Foramen intervertebrale,
the place where the spinal nerves arise
- two bony blades (Lamina) between vertebral pedicle and spinous process, filling the
foramen vertebrale’s circumference.
- spinous process (Processus spinosus) - a proeminent blade that extends back from
vertebral arch;
- transverse processes (Processus transversus)–pair prominent projections, which
arise from the sides of the vertebral arch;
- articular processes (Processus articularis) in number 4, 2 pairs superior and
inferior, serve to articulate the vertebras in between them.

Vertebra’s regional features.

Cervical vertebras:
 - Processus transversus is perforated by the foramen transversum(Foramen
transversus)which is bordered by Tuberculum anterius and Tuberculum posterius. The
superior surface, it’s crossed by the grooves of the spinal nerves (Sulci nervi spinales).
- Vertebral body is smaller and elongated transversely.
- Spinous process is short and presents a splited tip.
- Articular processes are oriented by in an almost horizontal plane.

Thoracic vertebras:
- Vertebral body is slightly elongated anterior-posterior and presents four
semicirculary articulary surfaces (Fovea costalis), two pairs superior and inferior. Toghether
withribs head, they form the costovertebral joints.
- Spinous process has a triangular prism shape;
- Processus articularis presents more a vertical direction.
- Processus transversus presents an articulary surfaces for the tuberculum
costalis called fovea costalis transversalis.

Lumbar vertebras:
- Vertebral body is large transversally;
- Spinous process is rectangular and well developed;
- Articular processes have a vertical direction;
- Processus transversus is low developed.
-In addition, at the base of processus transversus is situated a small rounded
mass, the accesory process (Processus accesorius). Also, another small projection is attached
to the processus articularis superior – mamillary process (Processus mamillaris). Both
reprezents embrionary rests from ribs involution in this region and somethimes are named
costiform processes (Processus costarium).

Special vertebras – Atipical vertebras

Atlas
-Is the first cervical vertebra. Presents two lateral masses, an anterior and posterior
arch which surrounds the vertebral foramen. The vertebral body is absent.
- The lateral mass (Massa lateralis) presents:
-Fovea articularis superior-two articulary surfaces for the occipital condyles;
-Fovea articularis inferior– the articulary surfaces for the axis;
-Processus transversus.
- Arcus anterior presents:
-Tuberculum anterius– pointing anteriorlly on the median line.
-Fovea dentis-on the posterior surface, for the axis dens.
- Arcus posterior presents:
-Tuberculum posterius-pointing anteriorlly on the median line;
-Sulcus arteriae vertebralis– the groove of the vertebral arterie crosses the
anterior arch perpendicullary.

Axis
-Is the second cervical vertebra and the first cervical vertebra where body appears. On
the superior body surface, it presents a vertical bonie “tooth” (Dens), with two ariculary
surfaces:Facies articularis anterior and Facies articularis posterior.
 The 6th cervical vertebra presents a more developed anterior tuberculum on the
processus transversus - tuberculum of Chassaignac (Tuberculum caroticum).
The 7th cervical vertebra has the longest spinous process which is easly visibile on the
neck posterior region (Vertebra proeminens).
The first thoracic vertebra-presents on the vertebral body a full articulary surface
superior and a half one inferior.
The 11th and the 12th thoracic vertebras presents only a single full rounded articulary
surface on the vertebral bodies (fovea costalis) situated in the middle.

THE SACRUM BONE

(Os sacrum)

It’s situated posterior and in between the two coxal bones.

Faces and parts:
-The anterior surface (Facies pelvina) presents:
-Liniae transversae-transversal lines whichremind the join of fused sacral
vertebras.
-Foramina sacralia pelvina–pair oriffices lateral to the transversal lines;
-The posterior surface (Facies dorsalis);
-Crista sacralis mediana-the join of processus spinosus of each sacral
vertebra.
-Crista sacralis intermedia-the join of the articulary processes.
-Crista sacralis lateralis-the join of processus transversus.
-Hiatus sacralis-the entrance in the sacral canal (Canalis sacralis)-the
inferior part of canalis vertebralis.
-Foramina sacralia dorsalia- four paired oriffices in between crista sacralis
intermedia and crista sacralis lateralis.
-The lateral face(Facies lateralis) presents:
-Facies auricularis–the articulary surface for the sacroiliac joint.
-Tuberositas sacralis – for ligaments insertions.
-The superior surface(Basis osis sacri) points to the 5th lombar vertebra and presents
two processus aricularis.
-The inferior extremity(Apex osis sacri) articulates with the coccygeum bone.
 THE BONES OF THE HEAD
(OSSA CRANII)

A.THE BONES OF THE NEUROCRANIUM

(OSSA NEUROCRANII)

THE FRONTAL BONE (OS FRONTALE)

- it is a flat bone, single, being placed on the antero-superior part of the skull
- it consists in four parts: the scale, the orbital part, the nasal part, the frontal
sinus (squama frontalis, pars orbitalis, pars nasalis and sinus frontalis)

a. THE FRONTAL SCALE (SQUAMA FRONTALIS)

- it situated anteriorly forming the antero-superior part of the skull
- it presents two surfaces: external and internal:
I. FACIES EXTERNA presents:
- margo supraorbitalis - the supraorbital margin represents the border in
between the frontal and the orbital parts
- incisura supraorbitalis / foramen supraorbitale - the supraorbital
notch / hole is situated on the lateral part of the supraorbital margin
- incisura frontalis / foramen frontale – the frontal notch / holeis
situated on the medial part of the supraorbital margin
- processus zygomaticus - the zygomatic process represents the lateral
continuation of the supraorbital margin
-margo parietalis - the parietal margin represents the border in between the
frontal and the parietal bone
-margo sphenoidalis - the sphenoid margin represents the border in
between the frontal and the sphenoid bone
-arcus supraciliaris - the supraciliar arch is a linear eminentia situated
above the supraorbital margin
-tuber frontale - the frontal tuber is a circular eminentia situated above the
supraciliar arch
-glabella - small flat portion situated in between the medial ends of
supraciliar arch
- linea temporalis - the temporal line represents the posterior continuation
on the infero-lateral aspect of the frontal scale

II. FACIES INTERNA presents:

- crista frontalis - the frontal crest situated vertically on the median line
-foramen caecum - the blind hole situated at the inferior end of crista
frontalis
-sulcus sinus sagitalis superioris - the groove of the superior sagital sinus
starts at the superior end of crista frontalis
-foveolae granulares - small holes situated in the groove

b. THE ORBITAL PART (PARS ORBITALIS)

- it is a pair part situated inferiorly forming the superior part of the orbit
 - it presents two horizontall lamellas separated by a notch
I. FACIES ORBITALIS - is concave, smooth and presents:
- fossa glandulae lacrimalis - the lacrimal gland’s fossa is situated on the
lateral side
-fovea trochlearis - the trochlear fossa (smaller) for the insertion of the
techlea of the oblique superior muscle of the eye
-margo sphenoidalis - the sphenoid margin represents the border in
between the frontal and the sphenoid bone
-arcus supraciliaris - the supraciliar arch is a linear eminentia situated
above the supraorbital margin

II. FACIES ENDOCRANII - is convex and presents:

- impressiones digitatae - the digital impressions and mamillar eminentias
(the imprints of the cerebral lobi)

III. INCISURA ETHMOIDALIS - the ethmoidal notch is situated in

between the orbital parts; it will articulate with the horizontal part of the ethmoidal
bone and presents:
- foramen ethmoidale anterius and posterius – the anterior and posterior
etyhmoidal holes through wich the orbit communicates with the endo-cranium
- celullaesfrontalo-ethmoidalis - small cavities in between these two bones

d. THE NASAL PART (PARS NASALIS)

- it is situated in between the orbital parts; it will articulate with the
nasalbones and with the nasal projection of maxilla bone; it presents:
- spina nasalis - the nasal spine oriented inferiorly

e. THE FRONTAL SINUS (SINUS FRONTALIS)

- it is a pair cavity situated in the base of squama frontalis
- septum intersinusale frontale - the frontal intersinusal sept represents a
splitting wall in between the two sinuses (right and left)
- apertura sinus frontalis - it is a hole through wich the frontal sinus
communicates with the nasal cavity

THE PARIETAL BONE

(OS PARIETALE)

- it is a flat bone, pair, being placed on the lateral sides of the skull
- it presents in two surfaces, four margins and four angles

a. FACIES EXTERNA is convex and presents:

- foramen parietale - the parietal hole situated near the superior margin and
the occipital angle
-tuber parietale - the parietal tuberosity situated in the superior part
-linea temporalis superior - the superior temporal line with a covex shape
and situated under tuber parietale
- linea temporalis inferior - the inferior temporal line with a covex shape
and situated under linea temporalis superior
 b. FACIES INTERNA is concave and presents:
- impressions digitatae - the digital impressions and mamillar eminentias
(the imprints of the cerebral lobi)
-sulci arteriosi - arteriolar grooves
-foveolae granulares - small cavities
-sulcus sinus sagitalis superioris - the groove of the superior sagital sinus
goes along the superior margin
-sulcus arteriae meningae mediae - the groove of the medial meningeal
artery goes along the middle part

c. MARGINS:
- margo sagittalis - the superior margin (makes with the opposite one the
sutura sagittalis)
- margo squamosus - the inferior margin (makes with squama temporalis
the sutura squamosa)
- margo frontalis - the anterior margin (makes with squama frontalis the
sutura coronalis)
- margo occipitalis - the posterior margin (makes with squama occipitalis
the sutura lambdoidea)

d. ANGLES:
- angulus frontalis - the antero-superior angle
- angulus occipitalis - the antero-posterior angle
- angulus sphenoidalis - the antero-inferior angle
- angulus mastoideus - the antero-posterior angle

THE OCCIPITAL BONE (OS OCCIPITALE)

-it is a flat bone, pair, being placed on the posterior side of the skull
- it presents three parts related to the central big hole (foramen magnum):

a. PARS BASILARIS - the basal part is situated anteriorly to foramen magnum

and presents:
I. FACIES EXTERNA - is convex, smooth and presents:
- tuberculum pharingeum - the pharingian tubercle in the middle of the
surface
II. FACIES INTERNA - is concave and presents:
- clivus - the slope that goes downwards to foramen magnum
- sulcus sinus petrosi inferioris - the pair grooves on the lateral margins of
this surface

b. PARS LATERALIS - the lateral pair part is situated laterally to foramen

magnum and presents:
I. FACIES EXTERNA presents:
- condylus occipitalis - the two pair elongated eminentias wich are oriented
oblique to posterior and lateral
- fossa condylaris - the depression situated posterior to the condyls
- canalis condylaris - the chanell situated in fossa condylaris
 - canalis hypoglossi - the chanell situated transversal in the base of the
condyls

II. FACIES INTERNA presents:

- tuberculum jugulare - the two pair elongated eminentias wich are
oriented oblique to posterior and lateral
- incisura jugularis - the jugular notch is situated laterally to tuberculum
jugulare on the lateral margin of this part
-processus intrajugularis - the intrajugular process situated in the middle of
the jugular notch
-processus jugularis - the jugular process situated at the posterior end of the
jugular notch
- sulcus sinus sigmoidei - the grove of the sigmoidian sinus is situated on
the medial side of the jugular process

c. SQUAMA OCCIPITALIS - the occipital scale is situated superiorly and

posteriorly to foramen magnum and presents:
I. FACIES EXTERNA wich presents:
- protuberantia occipitalis externa - the external occipital protuberantia
situated in the middle of the surface
- crista occipitalis externa - the crest that goes downwards from the
protuberantia to foramen magnum
-linea nuchalis superior - the superior nuchal line situated laterally to
protuberantia occipitalis
-linea nuchalis inferior - the inferior nuchal line situated inferiorly to
protuberantia occipitalis
-linea nuchalis suprema - the suprem nuchal line situated superiorly to
protuberantia occipitalis

THE TEMPORAL BONE (OS TEMPORALE)

- it is a pair bone, being placed on the infero-lateral sides of the skull,

under the parietal bone
- it presents four parts

a. PARS PETROSA - the “stone” part is situated in the middle of the bone,
having a pyramid shape with the base oriented laterally and the tip oriented medially:
I. FACIES ANTERIOR - the anterior surface situated endocranially, presents:
- impressio trigeminalis - the trigeminal imprint situated posterior to the
tip
- eminentia arcuata - the arched eminetia is situated in the middle of the
surface
- tegmen tympani - the ceiling of the tympanic cavity is situated laterally to
eminentia arcuata
- hiatus and sulcus nervi petrosi majoris - the opening and the groove of
the big stone’s nerve is situated antero-laterally to eminentia arcuata, going to the
tip of the pyramid
 - hiatus and sulcus nervi petrosi minoris - the opening and the groove of
the small stone’s nerve is situated antero-laterally to eminentia arcuata going to the
tip of the pyramid under the previous one

II. FACIES POSTERIOR - the posterior surface situated endocranially,

presents:
- porus acusticus internus - the internal orifice of the acustic chanell,
situated in the middle of this surface
- meatus acusticus internus - the continuation as an internal chanell of the
previous orifice into the core of the part petrosa
- crista transversa - at the end of it the surface of the chanell is split
in four by a transversal crest and the vertical crest
- crista verticalis - at the end of it the surface of the chanell is split
in four by a vertical crest and the transversal crest
- area facialis - the facial area represents the antero-superior window
of the split (in four) end of the chanell
- canalis facialis - the facial chanell starts at the level of area facialis,
contains the facial nerve and goes deeper into the bone having initially a
orizontal direction
- geniculum nervi facialis - the knee of the
facial nerve represents the point where the chanell change the
direction by going downwards vertically to be open on the inferior
surface of the pars petrosa
- fossa subarcuata - the under-arch depression, situated supero-laterally to
porus acusticus internus
- apertura externa aqueductus vestibuli - the external openind of the
aqueduct of the vestibule is situated laterally to porus acusticus internus

III. FACIES INFERIOR - the inferior surface situated exocranially, presents:

- canalis caroticus - the carotic chanell with it’s opening, situated near to
the tip of the pars petrosa
- canaliculi carotico-tympanici - the carotico-tympanic chanells
are very fine and they start in the carotic chanell, than they are going into
the tympanic cavity
- fossa jugularis - the jugular depression is situated in the middle of the
surface
- canaliculus mastoideus - the mastoidian chanell is very fine and it
starts in the fossa jugularis, than it goes into the pars petrosa
- fossula petrosa - the petrossa depression is small and triangular as shape,
being situated in between the canalis caroticus and fossa jugularis
-canaliculus tympanicus - the tympanic chanell is very fine and it is
open in fossula petrosa
- canaliculus cochleae - the cochlear chanell is very fine and it is
open in fossula petrosa
- foramen stylo-mastoideum - the stylo-mastoidian opening is situated in
the lateral part of the surface and represents the external opening of canalis facialis
- processus styloideus - the styloidian projection is situated in the lateral
part of the surface near foramen stylo-mastoideum
 -crista tegmentalis - the tegmental crest is a fine lamella wich goes
inferiorly into the fissura tympano-squamosa (situated in between pars squamosa
and pars tympanica)
IV. APEX PARTIS PETROSAE - the tip of the pars petrosa is oriented to the
junction in between the body and the big wing of the sphenoid bone where they delimit
the anterior lacerated opening (foramen lacerum); it presents:
- canalis caroticus - the carotic chanell with it’s opening
- canalis musculo-tubarius - the musculo-tubar chanell is situated near
canalis caroticus and communicates with the tympanic cavity
- septum canlis musculo-tubarii - the septum of the musculo-tubar
chanell wich splits the chanell in two half-chanells:
- semi-canalis musculi tensoris tympani - the superior half-
chanell of the tensor muscle of the tympan
- semi-canalis musculi tubae auditivae - the inferior half-
chanell of the auditiv tuba

IV. MARGO - the margins of the pars petrosa:

- margo superior - the superior margin situated in between facies anterior
and posterior; it presents:
- sulcus sinus petrosi superioris - the groove of the superior
petrosal sinus
- margo anterior - the anterior margin wich delimits with the big wing of
the sphenoid bone sutura spheno-petrosa
- margo posterior - the posterior margin is oriented to the occipital bone
and presents:
- sulcus sinus petrosi inferioris - the groove of the inferior petrosal
sinus
- incisura jugularis - the jugular notch is situated in the middle of
the margin (corresponds to the omonime one from the occipital bone)
- processus intrajugularis - the intrajugular process situated
in the middle of the jugular notch (corresponds to the omonime one
from the occipital bone)

b. PARS MASTOIDEA - the mastoidian part is situated at the base/ under pars
petrosa, posterior to porus acustics externus and presents:
I. FACIES EXTERNA - the external surface wich presents:
- processus mastoideus - the mastoidian projection oriented inferiorly
- cellulae mastoideae - the mastoidian cells are cavities inside of the
mastoidian process
- antrum mastoideum - the communication in between the
mastoidian cells and the tympanic cavity
- incisura mastoidea - the mastoidian notch situated on medially to
processus mastoideus
- sulcus arteriae occipitalis - the groove of the occipital artery situated
medially to incisura mastoidea
- foramen mastoideum - the mastoidian opening situated in the posterior
part of this surface
- spina suprameatum - the supra-meatal spine situated above the porus
acustics externus
 II. FACIES INTERNA - the internal surface wich presents:
- sulcus sinus mastoidei - the groove of the mastoidian sinus (here it will
open foramen mastoideum)

c. PARS SQUAMOSA - the “scale” part is thin being situated laterally, up to pars
petrosa and presents:
I. FACIES TEMPORALIS - the temporal (external) surface wich presents:
- processus zygomaticus - the zygomatic projection has two roots (anterior
and posterior) and it is oriented anteriorly where it will articulate with the temporal
projection of the zygomatic bone creating arcus zygomaticus
- tuberculum articulare - the articular tubercle is a rounded eminentia
situated medially to the anterior root of the processus zygomaticus
- linea temporalis - the temporal line oriented posteriorly in continuation of
the posterior root of the processus zygomaticus
- fossa mandibularis - the mandibular depression has an ellipsoid shape and
it is posterior to tuberculum articulare

II. FACIES CEREBRALIS - the cerebral (internal) surface wich presents:

- impressions digitatae - the digital impressions and mamillar eminentias
(the imprints of the cerebral lobi)
- sulcus arteriae meningae mediae - the groove of the medial meningeal
artery

d. PARS TYMPANICA - the tympanic part is situated inferiorly to pars

squamosa and anteriorly to pars mastoidea; it presents:
- porus acusticus externus - the external orifice of the acustic chanell; it is
situated inferiorly to the posterior root of the zygomatic projection
- meatus acusticus externus - the continuation as an internal chanell of the
previous orifice into the core of the pars tympanica (being open finally in the
tympanic cavity)
-sulcus tympanicus - the groove wich represents the insertion line of the
tympanic membrane; it is situated at the internal end of the meatus acusticus
externus

Pars tympanica togheter with the other parts of the temporal bone are
delimiting several fissures:
- fissura tympano-squamosa - in between the superior margin of pars
tympanica and pars squamosa
- fissura tympano-mastoidea - in between pars mastoidea and pars
squamosa
- fissura petro-tympanica “GLASER” - in between pars petrosa (crista
tegmentalis) and pars tympanica
- fissura petro-squamosa - in between pars petrosa (crista tegmentalis) and
pars squamosa

THE SPHENOID BONE (OS SPHENOIDALE)

 - it is an odd bone placed on the middle of the skull
- it presents four parts

a. CORPUS OSSIS SPHENOIDALIS - the body part is situated in the middle of

the bone, having a cube shape and presenting in the middle of it a pneumatic space (sinus
sphenoidalis) split in two parts by a septum (septum intersinusale sphenoidale); it
presents:
I. FACIES SUPERIOR - the superior surface having a saddle shape (sella
turcica) and facing endocranially, presents:
- fossa hypophisialis - the hypophisal depression situated in the middle of
the surface
- dorsum sellae - the posterior part of the saddle, presenting supero-laterally
two small projections:
- processus clinoideus posterior
- tuberculum sellae - the saddle’s tubercle situated in front of the saddle
- sulcus prechiasmatis - the ante-chiasmatic groove, situated in front of the
tubercle

II. FACIES INFERIOR - the inferior surface facing exocranially, presents:

- rostrum sphenoidale - the sphenoidal beak, situated on the middlew of
the surface

III. FACIES ANTERIOR - the anterior surface facing to the nasal cavities,
presents:
- crista sphenoidalis - the sphenoidal crest, situated vertically on the middle
of this surface
- apertura sinus sphenoidalis - the openings of the sphenoidal sinuses
situated on each side of the sphenoidal crest

IV. FACIES POSTERIOR - the posterior surface articulates with pars basilaris
of the occipital bone:

V. FACIES LATERALIS - the lateral surfaces facing endocranially,

representing the implantion surface for the big and small sphenoidal wings; it presents:
- sulcus caroticus - the carotic groove, situated superiorly to the root of the
big wings

b. ALA MAJOR OSSIS SPHENOIDALIS - the big wings, presents:

I. FACIES CEREBRALIS - the cerebral surface, concave and facing
endocranially, presents:
- foramen rotundum - the round hole situated in the anterior part of the root
of the big wing
- foramen ovale - the oval hole situated posteriorly to the round hole
- foramen spinosum - the sharp hole situated posteriorly to the oval hole

II. FACIES ORBITALIS - the orbital surface, concave and facing exocranially,
is delimiting:
- fissura orbitalis superior - the superior orbital fissure, situated in the
between the surface and the small wing
 - fissura orbitalis inferior - the inferior orbital fissure, situated in the
between the surface and the maxilla bone

III. FACIES INFRATEMPORALIS - the infratemporal surface, situated

inferiorly and facing exocranially; it presents:
- crista infratemporalis - the infratemporal crest, it represents the border in
between this surface and facies temporalis
- spina ossis sphenoidalis - the spina of the sphenoid bone, situated near the
external opening of foramen spinosum

IV. FACIES TEMPORALIS - the temporal surface, situated laterally and

facing exocranially

V. FACIES MAXILALARIS - the maxillar surface, situated inferiorly to

facies orbitalis

VI. MARGO - the margins:

- margo frontalis - the frontal margin for squama ossis frontalis
- margo squamosus - the “scale” margin for squama ossis temporalis
- margo petrosus - the petrosal margin for pars petrosa ossis temporalis
- margo zygomaticus - the zygomatic margin for the zygomatic bone

- margo parietalis - the parietal margin for antero-inferior angle of the

parietal bone

c. ALA MINOR OSSIS SPHENOIDALIS - the small wings, situated superiorly

to the big wings, in orizontal plane; it present:
- canalis opticus - the optic chanell situated at the root of the small wing
- fissura orbitalis superior - the superior orbital fissure, situated in the
between the small wing and the orbital surface of the big wing
- processus clinoideus anterior - the anterior clinoidal projection situated in
the continuation of the posterior margin of the small wing

d. PROCESSUS PTERYGOIDEUS - the pterygoidian projections, starts from

the inferior surface of the body of the sphenoid bone being oriented vertically and having
two parts=lamellas (lamina lateralis and medialis); it present:
- sulcus pterygo-palatinus - the pterygo-palatin groove oriented vertically
and situated on the anterior surface of procesus pterygoideus
- fossa pterygoidea - the pterygoidian fossa, situated posteriorly in the
between the two lamellas of processus pterygoideus
- incisura pterygoidea - the pterygoidian notch, situated inferiorly in the
between the tips of the two lamellas of processus pterygoideus
- fossa schapoidea - the schapoid fossa, a small depression situated
posteriorly at the base of the medial lamella
- hamulus pterygoideus - the pterygoidian hook situated posteriorly at the
of the medial lamella
- canalis pterygoideus - the pterygoidian chanell oriented horizintally and
situated in the root of procesus pterygoideus

B.THE BONES OF THE VISCEROCRANIUM

 (OSSA VISCEROCRANII)

THE ETHMOIDAL BONE (OS ETHMOIDALE)

- it is an odd bone, being placed on the antero-medial part of the base of the
skull
- it consists in three parts: the perforated (horizontal) lamella, the perpendicular
(vertical) lamella and the ethmoidal labyrinth

a. LAMINA CRIBROSA - the perforated lamella has a quadrilater shape abs it

wil be inserted into the ethmoidal notch of the frontal bone; it presents:
- foramina cribrosa - the perforated holes for the olfactive nerves

b. LAMINA PERPENDICUARIS - the perpendicular lamella it will be a

component of the nasal septum; it presents:
- crista galli - this crest represents the superior end of the lamina
perpendicularis being situated endocranially
- ala cristae galli - the wings of the crest; they continue the crest
anteriorly on each side of the foramen caecum

c. LABYRINTHUS ETHMOIDALIS - the ethmoidal labyrint are suspended

simetrically on the lateral margins of lamina cribrosa being situated in between the nasal
and orbital cavities; interiorly they presents pneumatic cells (cellulae ethmoidales)
arranged in three groups (anterior, middle and posterior) - some of these cells are
hemicells, being completed by the hemicells from the frontal bone; it presents:
I. FACIES LATERALIS - the lateral surface presents
- lamina orbitalis - the orbital lamella (it is a component of the medial wall of
the orbit)

II. FACIES MEDIALIS - the medial surface is a component of the lateral

wall of the nasal cavity and presents:
- concha nasalis superior - the superior nasal concha, a curved lamella
oriented medially
- concha nasalis media - the middle nasal concha, a curved lamella oriented
medially and situated under the superior nasal concha
- concha nasalis suprema - the supreme nasal concha, a curved smaller
lamella oriented medially and situated up to the superior nasal concha
- meatus nasi superior - the superior nasal meatus represents the space
situated under concha nasalis superior (in between it and labyrinthus ethmoidalis)
- meatus nasi medius - the middle nasal meatus represents the space
situated under concha nasalis media (in between it and labyrinthus ethmoidalis)
- infundibulum ethmoidalis - the ethmoidal infundibulum represents
the funnel shaped anterior part of the meatus nasi medius; here will open the
sinus frontalis and the anterior ethmoidal cells
- bulla ethmoidalis - the ethmoidal bulging situated in meatus nasi medius
- processus uncinatus - the sword-like projection oriented infero-posteriorly
and being situated in meatus masi medius, under bulla ethmoidalis
 - hiatus semilunaris - the semilunar opening represents the plane situated in
between bulla ethmoidalis and processus uncinatus; through this opening the nasal
cavity communicates with the maxillar sinus

THE NASAL BONE (OS NASALE)

- it is a small bone with a quadrilater shape, being placed antero-superiorly in

between the nasal part pf the frontal bone and the frontal process of the maxilla; it
presents:
a. FACIES EXTERNA - the external surface with a convex architecture

b. FACIES INTERNA - the internal surface with a concave architecture

oriented to the nasal cavity; it presents:
- sulcus ethmoidalis – the ethmoidal groove situated longitudinally along
this surface

THE LACRIMAL BONE (OS LACRIMALE)

- it is a small bone situated in the anterior part of the medial wall of the orbit; it
presents:
a. FACIES LATERALIS - the lateral (orbital) surface orineted to the orbital
cavity; it presents:
- crista lacrimalis posterior - the posterior lacrimal crest situated vertically
along this surface
- hamulus lacrimalis - the lacrimal hook situated at the inferior end of
crista lacrimalis
- sulcus lacrimalis - the lacrimal groove situated vertically in front of crista
lacrimalis; togheter with its omonime groove and crest from maxilla it will delimit
fossa saci lacrimalis
- canalis naso-lacrimalis - the naso-lacrimal chanell wich will connect
the orbit with the nasal cavity; it represents the inferior continuation of the
fossa saci lacrimalis

b. FACIES MEDIALIS - the medial surface oriented to the nasal cavity

THE INFERIOR CONCHAL BONE

(OS CONCHA NASALIS INFERIOR)

- it is a curved lamella situated on the inferior part of the lateral wall of the nasal
cavity (inferior to concha nasalis media of the ethmoid bone), being articulate with the
conchal crest of the maxilla and the palatin bone; it presents:
a. FACIES LATERALIS - the lateral surface, concave oriented to the sinus
maxillaris; it presents:
 - meatus nasi inferior - the inferior nasal meatus represents the space situated
under concha nasalis inferior

b. FACIES MEDIALIS - the medial surface oriented to the nasal cavity

c. PROCESSES - the projections emerging from the superior margin:

- processus lacrimalis - the lacrimal projection situated anteriorly and
oriented superiorly in order to participate to the delimitation of the naso-lacrimal
chanell
- processus ethmoidalis - the ethmoidal projection situated posteriorly and
oriented superiorly in order to articulate with the posterior end of processus uncinatus
- processus maxillaris - the maxillar projection situated in the middle and
oriented laterally in order to articulate with the inferior margin of hiatus maxillaris

THE VOMER BONE

(OS VOMERIS)

- it is a lamella situated medio-sagitally in the nasal septum; it presents:

a. MARGO SUPERIOR - the superior margin split in two:
- ala vomeris - the wings of the vomer wich will have in between them
rostrum sphenoidale
b. MARGO INFERIOR - the inferior margin wich articulates with the nasal
crest of maxilla and palatin bones
c. MARGO ANTERIOR - the anterior margin eich articulates with lamina
perpendicularis of the ethmoid bone
a. MARGO POSTERIOR - the posterior margin wich ends free

THE PALATIN BONE

(OS PALATINUM)

- it is a bone with a “L” shape, situated posterior to maxilla, being a component

of the hard palatum, orbital cavity, nasal cavity and of the pterygo-palatin fossa; it
presents:
a. LAMINA HORIZONTALIS - the horizontal lamella, represents the posterior
third of the hard palatum being articulated with the oppsosite one; it presents:
I. FACIES NASALIS - the superior (nasal) surface wich delimits posteriorly
the nasal cavities and presents:
- crista nasalis - the nasal crest situated on the medial line
- spina nasalis posterior - the posterior end of the nasal crest

II. FACIES PALATINA - the inferior (palatin) surface wich presents:

- foramina palatine minora - the small palatin holes
- canales palatini minores - the small palatin chanells wich communicate
with the pterygo-palatin chanell

b. LAMINA PERPENDICULARIS - the perpendicular lamella wich articulates

with maxilla bone and with processus pterygoideus; it presents:
 I. FACIES MAXILLARIS - the maxillar (lateral) surface represents the
medial wall of fossa pterygo-palatina; it presents:
- sulcus palatinus major - the big palatin groove; with its omonime groove
from the processus pterygoideus delimit canalis palatinus major (=canalis pterygo-
palatinus)

II. FACIES NASALIS - the nasal (medial) surface oriented to the nasal
cavity being a part of the lateral wall of nasal cavity; it presents:
- crista ethmoidalis - the ethmoidal crest situated superiorly; it will serve to
articulate with concha nasalis media
- crista conchalis - the conchal crest situated inferiorly; it will serve to
articulate with concha nasalis inferior
c. PROCESSES:
- processus orbitalis - the orbital projection emerge from the anterior end of the
superior margin of lamina perpendicularis; it is oriented antero-laterally being a part of
the inferior wall of the orbital cavity
- processus sphenoidalis - the sphenoidal projection emerge from the
posterior end of the superior margin of lamina perpendicularis; it is oriented to corpus
ossis sphenoidalis
- incisura spheno-palatina - the spheno-palatin notch it is situated on
the superior margin of lamina perpendicularis, in between processus orbitalis
and processus sphenoidalis
- foramen spheno-palatinum - the spheno-palatin hole is delimited by
incisura spheno-palatina (inferiorly) and corpus ossis sphenoidalis (superiorly)
- processus pyramidalis - the pyramidal projection emerge from the external
surface of the angle in between lamina perpendicularis and horizontalis; it is oriented
postero-laterally and situated in incisura pterygoidea of the pterygoid process of the
sphenoid bone

THE ZYGOMATIC BONE

(OS ZYGOMATICUM)

- it is a bone situated on the supero-lateral part of the face, having three surfaces
and processes and interiorly presenting a chanell (canalis zygomaticus) wich has a “Y”
shape; it presents:
a. SURFACES:
- facies lateralis - the lateral surface, having a convex shape and looking
antero-laterally; in the middle of it there is an orifice (foramen zygomatico-faciale)
- facies temporalis - the temporal surface, having a concave shape and
looking towards fossa temporalis and infratemporalis; in the middle of it there is an
other orifice (foramen zygomatico-temporale)
- facies orbitalis - the orbital surface, having a concave shape and participatig
to the components of the lateral wall of the orbita; in the middle of it there is an other
orifice (foramen zygomatico-orbitale)

b. PROCESSES:
- processus frontalis - the frontal projection, starting from the supero-lateral
angle of the bone and being part of the “additus orbitae”
 - processus temporalis - the temporal projection, starting from the posterior
angle of the bone and being part of “arcus zygomaticus”
- processus maxillaris - the maxillar projection, starting from the antero-
inferior angle of the bone and being articulate with the zygomatic process of maxilla

THE MAXILLA (OS MAXILLA)

- it is a pair bone, being placed in between the nasal, orbital and oral cavities
and representing the support for the superior dental arch
- it consists in the body, the processs and the internal cavity (sinus maxillaries)

a. CORPUS MAXILLAE (the body of maxilla) presents:

I. FACIES ANTERIOR - the anterior surfacewich presents:
- margo infraorbitalis - the infraorbital margin represents the inferior
border of the orbital cavity
-incisura nasalis - the nasal notch wich is situated medially; represents the
anterior border of the nasal cavity, the two notches delimiting togheter apertura
nasi anterior or apertura piriformis
-fossa incisiva - the incisive depression is situated above the dental alveolas
of the incisive theet
-eminentia canina - the canine proeminency being given by the canine
dental alveola
-fossa canina - the canine depression is situate above the dental alveolas of
the premolar teeth
-foramen infraorbitale - the infraorbital opening of the omonime chanell,
being siuated in the supero-medial part of the canine fossa
- crista zygomatico-alveolaris - the zygomatico-alveolar crest represent the
posterior border of the anterior surface, being situated in between processus
zygomaticus of maxilla and the dental alveola of the first molar tooth

II. FACIES ORBITALIS – the orbital surface represents the floor of the orbital
cavity and presents:
- sulcus infraorbitalis - the infraorbital groove is situated on the posterior
side of the surface and it will be continued towards anteriorly by the infraorbital
chanell (canalis infraorbitalis) wich will open on the anterior surface by foramen
infraorbitalis

III. FACIES INFRATEMPORALIS - the infratemporal surface looks

posteriorly towards fossa pterygopalatina and presents:
- tuber maxillae - the maxillar tuberosity represents a eminency situated in
the middle of the surface
- foramina alveolaria - the alveolar orifices are situated in the middle of
the surface and are continued interiorly by alveolar chanells

IV. FACIES NASALIS - the nasal surface looks medially and participates to the
lateral wall of the nasal cavity and presents:
- hiatus maxillaris - the maxillar hiatus represents a large opening oriented
towards medial line
 - sulcus lacrimalis - the lacrimal groove is situated anterior to the maxillar
hiatus; it is delimited by two crest and completed by the lacrimal bone and the
lacrimal process of concha nasalis inferior - in the end forming canalis naso-
lacrimalis

b. PROCESSES - the processes are:

I. PROCESSUS FRONTALIS - the frontal projection situated antero-medially
and oriented towards the frontal process of the frontal bone; it presents:
- crista lacrimalis anterior - the anterior lacrimal crest is situated on the
lateral side of the process
- crista ethmoidalis - the ethmoial crest is situated on the medial and
superior side of the process and it is destined for the articulation with concha nasalis
media
- crista conchalis - the conchal crest is situated on the medial and inferior
side of the process and it is destined for the articulation with concha nasalis inferior

II. PROCESSUS ZYGOMATICUS - the zygomatic projection is oriented

towards laterally direction in order to articulate with the maxillar process of the
zygomatic bone

III. PROCESSUS PALATINUS - the palatinal projection situated medially in

horizontal plane, togheter the right and the left ones (sutured on the median line) are
separating the nasal from the oral cavity; it has interiorly a chanell (canalis incisivus); it
presents:
A. FACIES SUPERIOR - the superior surface represents the anterior 2/3
thirds of the floor of the nasal cavity and presents:
- crista nasalis - the nasal crest situated longitudinally on the midline and
represents posteriorly the support for the vomer bone and anteriorly the support for
the cartilagenous septum of the nose
- spina nasalis anterior - the anterior nasal spine is situated in the middle
point of the inferior border of aperture piriformis

B. FACIES INFERIOR - the inferior surface represents the anterior 2/3

thirds of the ceiling of the oral cavity (hard palatum) and presents:
- sulci palatini - the palatinal grooves are oblique and are destined for the
vessels and the nerves of palatum
- torus palatum - the palatinal tubercle is situated in the middle point of the
surface

C. CANALIS INCISIVUS - the incisive chanell is situated posterior to the

medial incisive teeths; it has the shape of “V” ot “Y” being made by two chanells
wich converg towards the oral cavity where they will open in foramen incisivum
(on the middle line)

IV. PROCESSUS ALVEOLARIS - the alveolar projection situated inferiorly

and oriented towards the oral cavity; it has a curved shape and togheter with the
omonime process of the mandibula is making the arcus alveolaris; it represents the
support for the superior teeth and presents:
 - alveoli dentales - the dental alveolas (16) are spaces in the alveolar
process bordered in between them by inter-alveolar septums (septa inter-
alveolaria)
- septa inter-radicularia - the inter-radicular septums are situated
inside of the dental alveolas and they compartimentate these spaces for the
roots of the tooth
- juga alveolaria - the alveolar imprints are the external shape of the dental
alveolas on the alveolar processus

c. SINUS MAXILLARIS - the maxillar sinus represents the space on the

interior of the maxilla bone

THE MANDIBULA (OS MANDIBULA)

- it is a singular bone, being placed in the inferior part of the face and represents
the support for the inferior dental arch
- it consists in the body, the branches and the internal chanell

a. CORPUS MANDIBULAE (the body of mandibula) has a horizontalized “U”

shape and presents:
I. BASIS MANDIBULAE - the base of the mandibula has two surfaces:
A. FACIES EXTERNA - the external surface wich presents:
- symphisis mandibulae (mentalis) - it is a vertical crest situated on
the midline and representing the suture line in between the two hemi-
mandibulas
- protuberantia mentalis - the mental protuberantia has a triangular
shape (with the base oriented downwards) being situated in the continuation of
the symphisis
- tuberculum mentale - the mental tubercle is situated at the right and
left extremities of protuberantia
- foramen mentale - the mental hole represents the anterior opening of
the mandibular chanell being situated posterior to the tubercle
- linea obliqua - the oblique line represents a line oriented posterior
and superior from the tubercle to the anterior margin of the mandibular branch

B. FACIES INTERNA - the internal surface wich presents:

- spina mentalis – the mental spines (4), two superior and two inferior,
are situated on the midline of the surface
- linea mylohioidea - the mylohioid line represents a line oriented
posteriorly from the spine to posterior margin of the mandibular branch
- fossa digastrica - the digastric fossa is situated antero-inferiorly near
the mental spine
- fovea sublingualis - the sublingual fovea is situated antero-laterally,
superior to linea mylohioidea
- fovea submandibularis - the submandibular fovea is situated
posterior to sublingual fovea, inferior to linea mylohioidea
- torus mandibularis - the mandibular tubercle is situated under the
premolar tooth
 C. PROCESSUS ALVEOLARIS - the alveolar projection situated
superiorly and oriented towards the oral cavity; it has a curved shape and
togheter with the omonime process of the mandibular is making the arcus
alveolaris; it represents the support for the inferior teeth and presents:
- alveoli dentales - the dental alveolas (16) are spaces in the alveolar
process bordered in between them by inter-alveolar septums (septa inter-
alveolaria)
- septa inter-radicularia - the inter-radicular septums are situated
inside of the dental alveolas and they compartimentate these spaces for the
roots of the tooth
- juga alveolaria - the alveolar imprints are the external shape of the
dental alveolas on the alveolar processus

II. RAMUS MANDIBULAE - the branch of the mandibula has a flattened

quadrilater shape and it is oriented posterior and superior being deviated laterally with 20-
25 degrees; it presents:
A. ANGULUS MANDIBULAE - the mandibular angle of 110-125
degrees

B. THE MARGINS OF THE BANCH OF MANDIBULA:

- margo superior - the superior margin presents:
- processus coronoideus - the coronoid projection is situated
anteriorly
- processus condylaris - the condylar projection is situated
posteriorly, being thicker than the coronoid one and presents:
- caput mandibulae - the head of the mandibula wich
presents an articular surface
- collum mandibulae - the neck of the mandibula
situated under the head
- fovea pterygoidea - the pterygioidian fovea situated
on the anterior side of the neck
- incisura mandibulae - the mandibular notch is situated in
between the two processes

- margo inferior - the inferior margin continues the inferior margin of

the body of mandibula
- margo posterior - the posterior margin is smooth
- margo anterior - the anterior margin presents:
- crista lateralis - the lateral crest is situated anteriorly and
goes towards linea obliqua
- crista medialis - the medial crest is situated posteriorly and
goes towards linea mylohioidea
- retromolar trigonum - the retromolar triangle is situated in
between the two crest, posterior to the last molar tooth

B. THE SURFACES OF THE BRANCH OF MANDIBULA:

- facies lateralis - the lateral surface presents:
- tuberositas masseterica - the maseter tuberosity is situated
on the lateral aspect of the angle of mandibula
- facies medialis - the medial surface presents:
 - foramen mandibulae - the mandibular hole represents the
posterior opening of the mandibular chanell being situated in the
middle of the surface
- lingula mandibulae “Spix” - the mandibular spine situated
anterior and superior to foramen mandibulae
- sulcus mylohioideus - the mylohioidian groove situated
under foramen mandibulae and oriented inferior and anterior
- tuberositas pterygoidea - the pterygioidian tuberosity is
situated on the medial aspect of the angle of mandibula

III. CANALIS MANDIBULAE - the chanell of the mandibula has a inferior and
anterior direction in between the two openings: foramen mandibulae and mentale.
 THE ORBIT

(CAVITAS ORBITALIS)

- it is a cavity situated on the anterior (facial) zone of the exobasis and it presents:
a. the BASE (Aditus Orbitalis) wich is delimited by:

- margo supraorbitalis - wich is given by margo supraorbitalis squama ossis frontalis

and processus zygomaticus ossis frontalis

- margo medialis – wich is given by processus frontalis maxillae

- margo infraorbitalis - wich is given by margo infraorbitalis maxillae (medially)

and os zygomaticum (laterally)

- margo lateralis – wich is given by processus frontalis os zygomaticum

b. the TIP (Apex with Canalis Opticus) wich is delimited by:

- the root of ala minor ossis sphenoidalis

- corpus ossis sphenoidalis

c. the WALLS wich are made by:

- superior wall - wich is given by facies orbitalis of pars orbitalis ossis frontalis

- lateral wall – wich is given by facies orbitalis ala major ossis sphenoidalis and
facies orbitalis os zygomaticum

- inferior wall – wich is given by facies orbitalis corpus maxillae and processus
orbitalis os palatinum

- medial wall – wich is given by processus frontalis ossis maxillae, os lacrimalis and
lamina orbitalis labyrinthus ethmoidalis

d. the COMMUNICATIONS:
- canalis opticus

- fissura orbitalis superior

- fissura orbitalis inferior

- foramen zygomatico-orbitalis

- foramen ethmoidalis anterior

- foramen ethmoidalis posterior

- canalis naso-lacrimalis

- canalis infraorbitalis

THE NASAL CAVITY

(CAVITAS NASALIS)

- it is a cavity situated on the anterior (facial) zone of the exobasis and it presents:

a. the anterior OPENING (Apertura Piriformis or Apertura Nasalis Anterior) is

delimited by:

- incisura nasalis maxillae

- os nasale

- spina nasalis anterior

b. the posterior OPENING (Choanae or Apertura Nasalis Posterior) is delimited by:

- corpus ossis sphenoidalis

- ala vomeris

- lamina horizontalis ossis palatinum

- lamina medialis processus pterygoideus ossis sphenoidalis

b. the WALLS wich are made by:

- superior wall - wich is given by pars nasalis ossis frontalis, lamina cribrosa ossis
ethmnoidalis and facies anterior corpus ossis sphenoidalis
- lateral wall – wich is given by processus frontalis maxillae, os lacrimalis, facies
nasalis corpus maxillae, cellulaes ethmoidales, labyrinthus ethmoidalis, concha
nasalis superior, concha nasalis media, concha nasalis inferior, lamina verticalis
ossis palatinum, lamina medialis processus pterygoideus ossis sphenoidalis

- inferior wall – wich is given by processus palatinum ossis maxillae, lamina

horizontalis ossis palatinum

- medial wall – wich is given by lamina perpendicularis ossis ethmoidalis, os

vomeris, crista sphenoidalis, rostrum sphenoidalis, crista nasalis

c. the COMMUNICATIONS:

- lamina cribrosa

- foramen ethmoidalis anterior

- foramen ethmoidalis posterior

- foramen spheno-palatinum

- canalis incisivus

- canalis pterygoideus

- hiatus semilunaris

- in meatus nassi superior there will be the opening of cellulae ethmoidales

posteriores, sinus sphenoidalis

- in meatus nassi medius there will be the opening of cellulae ethmoidales anteriores,
sinus frontalis, sinus maxillaris

- in meatus nassi inferior there will be the opening of canalis nazo-lacrimalis

FOSSA PTERYGO-PALATINA
- it is a cavity situated on the middle (jugular) zone of the exobasis and it presents:

a. the BASE situated superiorly and delimited by:

- facies inferior corpus ossis sphenoidalis

b. the TIP situated inferiorly and it is continuated in:

- canalis pterygo-palatinus

c. the WALLS wich are made by:

- anterior wall - wich is given by tuber maxillae

- posterior wall – wich is given by facies spheno-maxillaris corpus ossis sphenoidalis

and processus pterygoideus ossis sphenoidalis

- medial wall – wich is given by lamina verticalis ossis palatinum

- lateral wall – wich is not made by a bone but being an empty plane (fisura pterygo-
maxillaris) in between the other bones and representing the opening towards fossa
infratemporalis

c. the COMMUNICATIONS:

- fissura orbitalis inferior

- foramen rotundum

- canalis pterygoideus

- foramen spheno-palatinum

- fissura pterygo-maxillaris

- canalis pterygo-palatinus
 FOSSA INFRA-TEMPORALIS

- it is a cavity situated on the middle (jugular) zone of the exobasis and it presents:

a. the WALLS wich are made by:

- anterior wall - wich is given by facies infratemporalis maxillae

- medial wall – wich is given by lamina lateralis processus pterygoideus ossis

sphenoidalis, fissura pterygo-maxillaris

- lateral wall – wich is made by facies temporalis os zygomaticum, facies medialis

ramus mandibulae

- superior wall – wich is made by facies infratemporalis ossis sphenoidalis

b. the COMMUNICATIONS:

- fissura orbitalis inferior

- fissura pterygo-maxillaris

- foramen ovale

- foramen spinosum

- foramen mandibulae
 JOINTS OF THE UPPER LIMB
(Juncturae membri superioris)

Joints of the upper limb divide in:

- Joints of the pectoral girdle;
- Joints of the free part of upper limb.

JOINTS OF THE PECTORAL GIRDLE

(Juncturae cinguli membri superioris)

The bones of the pectoral girdle (clavicula and scapula) articulate with eachother
through the acromioclavicular articulation, and by sternoclavicular articulation with the
skeletal trunk.

STERNOCLAVICULAR ARTICULATION
(Articulatio sternoclavicularis)

Bone components:
- Clavicular notch of sternum (Incisura clavicularis); concave with the longest axis
vertically.
- Sternal facet of the clavicle (Facies articularis sternalis): slightly convex, larger
than the sternal notch.
Cartilaginous components:
- articular cartilage (Cartilago articularis); it covers the articular surfaces of the
bone components, and is made up of a thin layer of fibrous cartilage.
- articular disk (Discus articularis); is a thin fibrous-connective formation, which
can be biconcave, or even perforated on the central part. It is interposed between incongruent
articular surfaces, and ensures concordance between them.
Connection means:
- Articular capsule (Capsula articularis); fibrous, and narrow; it surrounds the
whole articulation, and is attached to the articular surfaces. Like this, the entire sternal end of
the clavicle is intraarticular.
- Articular ligaments:
- Anterior and posterior sternoclavicular ligaments (Ligamentum
sternoclaviculare anterius et posterius) are found on the anterior and posterior surfaces of
the sternal end of the clavicle and sternal manubrium. The ligament is formed by strong
fibrous-connective bands that pass obliquely downwards and medially from the clavicle to
the sternum.
- Interclavicular ligament (Ligamentum interclaviculare) stretches between the
two sternal extremities of the clavicle. It is situated on the superior part of the articular
capsule and the jugular notch of the sternum. It fortifies the upper surface of the capsula.
- Costoclavicular ligament (Ligamentum costoclaviculare); it is situated between
the first rib (C1), and the impression for the costoclavicular ligament from the inferior surface
of the clavicle. It is a strong fibrous band situated on the medial side of the articulation. It
limits the elevation of the clavicle and compensates for the weaker inferior part of the
articular capsule.
Biomechanics:
Morphologically, it is not a typical joint (intermediary joint; between aplanee joint and
a saddle joint).
Functionally, it behaves like an enarthrosis with the following movements:
 - Lifting (50o) and depressing (5o) the clavicle around a sagittal axis that passes
through the sternal end of the clavicle.
- Forward and backward projection of the clavicle (30-30o) around a vertical axis
that passes through the sternal end of the clavicle.
- The circumduction of the clavicle results from the combination of the previous
movements. The clavicle’s motion forms an imaginary cone whose base is at the acromial
extremity of the bone.
Articular cavity: is divided by the articular disk in two compartments: the disk-
clavicular compartment, and the disk-sternal compartment. The internal face of the articular
capsule is covered by the synovial membrane in the two enclosed compartments.

ACROMIOCLAVICULAR JOINT
(Articulatio acromioclavicularis)

Bone components:
- Acromial articular surface (Facies articularis acromialis) of the clavicle is
ellipsoidal with the longest axistransversally.
- The articular surface from the acromion (Facies articularis acromii) is ellipsoidal
but flatter.
Cartilaginous components:
- Articular cartilage (Cartilago articularis) is fibrous (in rare situations hyaline)
and covers in a thin layer the articular surfaces in contact.
- Articular disk (Discus articularis) is fibrous, cartilaginous, and more attached to
the upper part of the capsule. It partially divides the articular cavity. It is missing in 60% of
cases.
Connection means:
- Articular capsule (Capsula articularis) is fibrous, tight, less resistant, and it
inserts on the borders of the articular surfaces.
- Articular ligaments are:
- Acromioclavicular ligament (Ligamentum acromioclaviculare); it is situated
on the superior surface of the articulation, between the acromion and the clavicle. It
strengthens and fixes the articular capsule.
- Coracoclavicular ligament (Ligamentum coracoclaviculare); placed between
coracoid process, and the inferior surface of the clavicle’s acromial end. It strengthens the
connection between the scapula and clavicle. It is composed of:
- Trapezoid ligament (Ligamentum trapezoideum); situated anteriorly and
laterally from the conoid ligament. It stretches from the superior surface of the coracoid
process to the trapezoid line of clavicle, becoming larger and being situated anteriorly and
laterally.
- Conoid ligament (Ligamentum conoideum); situated posteriorly and
medially from the previous. It is between the coracoid process and the conoid tubercle of the
clavicle. Posteriorly, on the coracoid process the two ligaments merge, and anteriorly they
have a divergent trajectory.
- Ligaments of scapula entirely belonging to the bone:
- Superior transverse scapular ligament (Ligamentum transversum scapulae
superior), closes the scapular notch converting it into a foramen.
Biomechanics.
It is a planee articulation acting simultaneously with sternoclavicular articulation, and
contributes to the movements of the pectoral arch, which are represented by the movements
of the shoulder and movements of the scapula.
 The shoulder, due to the movements of the collar bone and the gliding of the scapula on
the thoracic wall, executes movements of elevation and depression, movements of projection
forward and backward, and movements of circumduction.
The scapula, suspended to the acromioclavicular joint,is attached by muscles to the
thoracic wall (this connection is called “the interscapular-thoracic muscular junction”), and
executes movements of gliding medially, laterally, upward ,and downward. A characteristic
movement of scapula is the swinging of the inferior angle. In the axillary swinging
movement, the inferior angle moves forward, moving away from the vertebral column, and
simultaneously the lateral angle is moving upward. In the spinal swinging movement of the
shoulder blade, the movements are opposite. These movements serve to amplify the range of
motion of the arm.

JOINTS OF THE FREE PART OF UPPER LIMB

(Juncturae membri superioris liberi)

GLENOHUMERAL OR SHOULDER JOINT

(Articulatio humeri)

Bone components:
- The head of the humerus (Caput humer) is a spherical, smooth formation.
- The glenoid cavity (Cavitas glenoidalis) is oval shaped, concave, and with its
long axis situated vertically. It occupies a third of the articular surface of the humeral head.
Cartilaginous components:
- Articular cartilage (Cartilago articularis) is hyaline and covers the articular
surfaces.
- Glenoid ligament (Labrum glenoidale), is a fibrocartilaginous rim attached to the
margin of the glenoid cavity, ensuring a greater stability to the articulation.
Connection means:
Articular capsule (Capsula articularis) is a cylindrical sleeve. It is fibrous, lax, and
situated around the boney extremities. It ensures the freedom needed for the movements of
the articular surfaces with approximatively 20 mm. It consists of connective fibers grouped
in:
- Longitudinal superficial fibers; they are long, and stretch between the neck of
scapula and surgical neck of the humerus.
- Circular fibers; they are shorter, and situated deeper.
- Scapular insertion; it inserts on the neck of scapula, on the superior and posterior
side of the glenoid ligament, and embeds of the supraglenoid tubercle. The humeral insertion,
superiorly, is attached to the anatomical neck of the humerus; anteriorly, it descends up to the
surgical neck of the humerus; the greater tubercle and the lesser tubercle remain
extrascapular. The inferior part of the capsula is thin, lax, and weak. In the anatomical
position of the arm it forms an additional fold that disappears in abduction.
- Tendinous insertion expansions of the perihumeral muscles are involved in
strengthening the fibrous capsule as “articular muscles”: superior – supraspinatus muscle;
anterior – subscapularis muscle; posterior – infraspinatus and teres major muscles.
- The fibrous capsula has two important holes through which the extension of the
synovial membrane appear in the pericapsular space:
At the upper end of the intertubercular groove, an orifice for the tendon of the long head
of biceps brachii muscle.
- Inferior orifice, through which the synovial membrane communicates with
subcapsular bursa.
 Articular ligaments:
Capsular ligaments are fibrous bands considered as a thickening of the fibrous capsule:
- Glenohumeral ligaments (Ligamenta glenohumeralia): three fibrous longitudinal
ligaments that are situated on the anterior surface of the fibrous capsule;
- Superior glenohumeral ligament; passes anteriorly and laterally from the long
tendon of the biceps brachii muscle. It is stretched between the glenoid ligament and the
superior border of the lesser tubercle.
- Middle glenohumeral ligament; itpasses longitudinally across the anterior surface
of the fibrous capsule between the scapula and humerus.
- Inferior glenohumeral ligament; it is the strongest ligament, and is directed
downward and laterally between the anterior border of the glenoid ligament and anatomical
neck of humerus.
- Accessory ligaments:
- Coracohumeral ligament (Ligamentum coraco-humerale); it is situated between
the lateral border of the coracoid process and greater tubercle of humerus; it passes above the
articulation and strengthens the upper part of the fibrous capsula.
- Coracoacromial ligament (Ligamentum coraco-acromiale), or coracoacromial
fibrous arch (Fornix humeri); it is situated above the glenohumeral joint, and is not
connected with the fibrous capsule of the joint. It has a triangular shape, with the basis
oriented towards the lateral border of the coracoid process, and the peak oriented toward
acromion.
Articular cavity:
The internal surface of the articular capsule is covered by the synovial membrane, and
when the arm is near the body, parallel with its longitudinal axis, the capsula stretches
downwards toward humerus like a bag. It presents the following elements:
- Synovial sheath of the long tendon of biceps brachii muscle (Vagina synovialis
intertubercularis); this covers like a sleeve the intraarticular segment of the tendon in the
intertubercular groove.
- Periarticular bursas are extracapsular extensions of the synovial, placed under the
tendons of the periarticular muscles:
- Subacromial bursa (Bursa subacromialis);
- Subcoracoid bursa (Bursa subcoracoidea);
- Subdeltoid bursa (Bursa subdeltoidea);
- Subscapular bursa (Bursa subscapularis);
Scapulohumeral periarthritis, caused by the inflammation of the aforementioned bursas,
limits the movement of the arm.
Biomechanics: It is the most mobile enarthrosis of the body, and it takes place in the
following movements:
- Flexion, or onward projection of the arm (90-110o), around a transversal axis that
passes through the center of humeral head.
- Extension, or backward projection of the arm, around the same transversal axis; it
is smaller (35o).
- Abduction, or the movement of the arm away from the trunk, up to a horizontal
level (90o). Beyond it, the movement is impeded by the greater tubercle, which hits the
coracoacromial ligament.
- Adduction, or the arm approaching the trunk, is possible until the arm touches the
body. If adduction is performed in front of the torso, the joint allows an increase of the arm
adduction with 10o(ex. Crossing arms). Abduction, and adduction, are made around a sagittal
axis.
 - Internal rotation (80o) is executed around a vertical axis that unites the center of
the head with capitulum of the humerus.
- External rotation (50-60o) is made around the same vertical axis.
- Circumduction is obtained from the combination of the aforementioned
movements; the motions of the arm form a cone whose peak is oriented toward glenoid
cavity.
The movements of the pectoral arch amplify the movements of the arm so that it can
achieve the following dimensions:
- Flexion and abduction may lift the arm to a vertical position (elevation).
- Extension increases up to 50o.
- Internal and external rotations achieve 90-90o.

ELBOW JOINT
(Articulatio cubiti)

Particularities:
Elbow joint is a complex joint, made up from 3 articulations:
- Humeroulnar joint (Articulatio humero-ulnaris)
- Humeroradial joint (Articulatio humero-radialis)
- Radioulnar joint (Articulatio radio-ulnaris)
The articulation itself is formed by the inferior part of the humerus, and the superior
parts of radius and ulna. The proximal radioulnar joint will be described separately.
Bone components:
- Humeral trochlea (Trochlea humeri); has the shape of a sandglass, is positioned
horizontally, and is slightly oblique.
- Capitulum of humerus (Capitulum humeri); is spheroid in shape.
- Olecranon fossa (Fossa olecrani).
- Trochlear notch (Incisura trochlearis) of the ulna for humeral trochlea.
- Articular facet of head of radius (Fovea capitis radii).
Cartilaginous components:
- Cartilaginous surfaces are covered by a layer of hyaline cartilage that ensures a
perfect contact between the bones.
Connection means:
The fibrous capsule covers the entire articulation. It is more lax on the posterior surface,
and thinner on the anterior and posterior surface; it is stronger, and strengthened by ligaments
on the lateral surface. Articular capsule is made of connective fibers with the following
arrangement:
- On the anterior surface of the capsule, are mainly longitudinal fibers.
- On the posterior surface, the capsule is more lax, and in the middle part of the
surface, the fibers are more profound and stretched between the borders of olecranon fossa
and the border of olecranon. Some fibers form transverse strips that cross the olecranon. The
capsule is fortified by the insertion of the fibers of the triceps brachii tendon. On the lateral
sides of the posterior surface, the capsular fibers pass from the posterior surface of the lateral
epicondyle to the posterior part of the radial notch of ulna and anular ligament.
- Humeral insertion of the fibrous capsule passes above the radial fossa, coronoid
fossa, and the borders of olecranon fossa; they are all being embedded in the articular cavity.
Laterally, and medially, itpasses below medial and lateral epicondyles, which remain outside
the capsule.
- Ulnar insertion; it is situated on the borders of trochlear notch, so that the summit
of olecranon and coronoid process are situated inside the capsule.
 - Radial insertion; it passes around the neck of radius circularly.
Articular ligaments:
- Ulnar collateral ligament (Ligamentum collaterale ulnare) is made up from three
conjunctive bands radiating like a fan from the medial epicondyle to the medial border of the
trochlear notch.
- Radial collateral ligament (Ligamentum collaterale radiale); it is a strong band
triangular, and is placed between the lateral epicondyle; there, it forms a strap over the head
of radius and ends on the superior extremity of ulna, and on the anular ligament of radius.
Articular cavity:
- The synovial membrane follows the line of the fibrous capsule, andis reflected on
humerus (to delimit radial and coronoid fossae), and on the posterior surface olecranon fossa.
Distally, on radius, it covers the internal surface of the anular ligament, and ends around the
neck of radius. On the ulna it is anchored at the edge of radial notch, and at the edge of
trochlear notch. It forms synovial folds.
Biomechanics: seen as a humeral-forearm joint, it behaves like a hinge
joint(Gynglimus) in which the flexion and extension movements are given by the
glenohumeral joint. The movements are made around a transverse axis that crosses humeral
trochlea.
Due to the fact that this axis has an oblique orientation, the axis of the forearm will not
continue in the same axis as that of the arm. This stands true in both flexion, and extension.
- Flexion reaches 40o measured between the axis of the arm and forearm. The
forearmin flexion moves slightly medially from the arm. The movement is limited by the
interposing of the soft tissue between the arm and forearm, and the entrance of the coronoid
process in the coronoid fossa.
- Extension is executed up to 180o, and the forearm will be slightly moved away
from the body during the motion. The movement is limited by the entrance of the olecranon
intothe olecranon fossa.

RADIOULNAR JOINTS
(Articulatio radioulnaris)

At the level of forearm, between radius and ulna, there are three connections that act
together to allow the movement of the radius on ulna around a vertical axis(pronation and
supination) namely:
- Proximal radioulnar joint.
- Radioulnar syndesmosis.
- Distal radioulnar joint.

PROXIMAL RADIOULNAR JOINT

(Articulatio radioulnaris proximalis)

Bone components:
- Radial notch of ulna; concave from anterior to posterior, and flat in the vertical
direction.
- Articular circumference of the radial head.

Cartilaginous components:
- Hyaline articular cartilage that covers the articular surfaces of the bones, and
belongs to the articulation of the elbow.
Connection means:
 - Fibrous capsule; it is common with the elbow articulation.
- Articular ligaments:
- Anular ligament (Ligamentum anulare) is a strong fibrous strip, which inserts
on the anterior and posterior borders of the radial notch of ulna. It forms 4/5 of a ring, which
ensures the maintenance of the head of radius in the ulnarconcavity; it is strengthen by the
fibers of the ulnar collateral ligament, and by the lateral side of the fibrous capsule of the
elbow.
- Quadrate ligament (Ligamentum quadratum); it is a quadrilateral fibrous
blade stretched between the inferior border of the radial notch, and the medial surface of the
radial neck.
Articular cavity:
- Synovial; from the articular cavity of the elbow, it covers the internal surface of
the fibrous capsule, the internal surface of the anular ligament, and continues towardsthe
quadrate ligament.

RADIOULNAR SYNDESMOSIS
(Syndesmosis radioulnaris)

They are fibrous formations stretched between the shafts of radius and the ulna:
Oblique cord (Chorda obliqua) is an oblique fibrous band stretched between the lateral
border of the ulnar tuberosity, and the inferior border of the radial tuberosity. The fibers are
oriented downwards and laterally; it is considered a degenerate portion of the supinatory
muscle.
Interosseous membrane (Membrana interossea antebrachii) is a strong blade that
closes the interosseous space stretched between the interosseous borders of radius and ulna.
The majority of the fibers are directed downwards and medially from the radius to the ulna.
- The superior border is oblique, free, and stretched about 2,5 cm beneath radial
tuberosity at the upper part of the interosseous border of ulna.
- The inferior border is situated above the radioulnar joint.
- The interosseous membrane presents numerous holes for vascular branches. It
ensures the transmission of the forces from the superior extremity of ulna to the distal
extremity of radius.

DISTAL RADIOULNAR ARTICULATION

(Articulatio radioulnaris distalis)

Bone components:
- Ulnar notch of radius.
- Articular circumference of the ulna head.
Cartilaginous components:
- Articular surfaces are covered by a thin layer of hyaline cartilage.
-The articular disk (Discus articularis), with a fibrocartilaginous structure, is
interposed between the two articular surfaces, triangular shaped, and is also known as the
triangular ligament. The base of the disk is directed upward and is fixed on the inferior border
of the ulnar notch of radius, and the peak is directed downward to the basis of the styloid
process of ulna and pyramidal bone. Anteriorly and posteriorly it fixates on the articular
capsule.
Connection means:
 Articular capsule (Capsula articularis) inserts superiorly on the superior borders of the
articular surfaces of the two bones; inferiorly it inserts on the articular disk, and inferiorly is
the same with the capsule of radiocarpal articulation.
Fortification ligaments of the articular capsule are transverse fibers called anterior and
posterior radioulnar ligaments.
Articular cavity:
- The articular disk divides the articular cavity into two narrow compartments. The
synovial membrane, which covers the internal surface of the fibrous capsule, sends a
sacciform extension to the radioulnar interosseous space (Recessus sacciformis).
Biomechanics: The two radioulnar joints act simultaneously and synergistically; each
are having the character of a trochoid joint in which the mobile bone is the radius. The radius
executes movements of internal and external rotation, but at the level of the forearm, and the
hand, those movements become pronation and supination movements. The axis of these
movements does not correspond with the vertical axis of radius, but rather it has an oblique
position that unites the center of the head of radius with the head of ulna.
To analyse the pronation and supination movements, we start from the forearm’s
physiological position, which is an intermediate position between these two movements. The
forearm hangs along the trunk with the palm oriented toward the body, and with the thumb
directed forward (upright position).
The pronation is the movement in which the palm is directed backward, and the thumb
is directed inwards. With the elbow flexed, the palm will be directed downward. The various
segments of the radius move will move in the following ways:
- The head of radius rotates in the radial notch, and isheld by the anular ligament, so
that it doesn’t move in any planee of direction.
- The inferior extremity rotates around the head of the ulna, and moves medially
from it. Like so, there is not only a simple rotation, but also a translation (movement) of the
inferior extremity of radius towards the ulna.
- The radial shaft crosses above the shaft of the ulna. This cross is achievable
because radial shaft is concave towards the ulna, and like this, it isforms the so called
“pronation curve”.
The supination is the movement opposite to pronation in which the palm is directed
forward, and the thumb is directed outward. With the elbow flexed the palm will be directed
upward.
The movements of the radius segments are opposite to those from pronation. The two
bones become parallel.
The pronation and supination movements combined, total 140o (70 – 70o), and can be
amplified up to 300o by the movements of internal, and external, rotation of the arm.

HAND ARTICULATIONS
(Articulatio manus)

It contains the articulations of hand bones and fingers articulations. Are divided in:
- Radiocarpal articulation;
- Intercarpal articulations;
- Carpometacarpal articulations;
- Intermetacarpal articulations;
- Fingers articulations;

RADIOCARPAL ARTICULATION
(Articulatio radiocarpea)
 It is an ellipsoidal articulation situated between the distal extremity of the radius and
proximal row of the carpus.
Bone components:
- The articular carpal surface of the radiusis a concave cavity that is ready to receive
an ovular structure. Its axis is orientedtransversely, and is divided by an anterior-posterior
ridge in a medial and lateral articular area. It represents 2/3 from the total articular surface.
- The superior surface of the scaphoid bone, lunate bone and pyramidal bone, make
a convexsemi-oval surface.
Cartilaginous components:
- Articular surfaces are covered by a hyaline cartilage.
- The fibrocartilaginous articular disk of the radioulnar articulation also stretches in
this articulation, and is interposed between the head of ulna and the pyramidal bone.
Connection means:
The articular capsule (Capsula articularis) is a fibrous structure which is lax
posteriorly. Superiorly, it inserts on the border of the articular surface of radius and on the
articular disk; inferiorly, it inserts at the edge of the carpal articular surface.
Ligaments:
- Palmar radiocarpal ligament (Ligamentum radiocarpeum palmare) is strong,
and it inserts on the anterior border of the articular surface of radius and styloid process. The
fibers pass in the shape of a fan on the carpal bones: lunate bone, pyramidal bone and capitate
bone.
- Palmar ulnocarpal ligament (Ligamentum ulnocarpeum palmare); it is situated
between articular disk, styloid process of ulna, lunate bone, pyramidal bone, and capitate
bone.
- Dorsal radiocarpal ligament (Ligamentum radiocarpeum dorsale) is the weaker
of the palmar ligaments;the fibers have an oblique trajectory. It is placed between the
posterior border of the radial articular surface and the posterior surface of the pyramidal
bone.
- Radial collateral ligament of wrist joint (Ligamentum collaterale carpi radiale)
stretches between the peak of the styloid process of radius and scaphoid bone.
- Ulnar collateral ligament of wrist joint (Ligamentum collaterale carpi ulnare) is
situated between the styloid process of the ulna, the pyramidal, and the pisiform bones.
Articular cavity:
The synovial membrane covers the fibrous capsule and ends at the edge of the articular
cartilage; it has a proximal extension that communicates with the cavity of distal radioulnar
articulation through a hole situated in the articular disk.
Biomechanics: it acts like an ellipsoidal articulation with two main axes. Around the
transverse axis, flexion and extension movements are possible, and around the anterior-
posterior axis, movements of abduction and adduction can be made.
- Flexion is the approach of the palm toward the anterior surface of the forearm
(palmar flexion) having an amplitude of 60-90o.
- Extension is the movement by which the dorsal surface of the hand approaches
the posterior surface of the forearm, and forming with it an angle of 60-90o.
- Abduction is the movement by which the external edge of the hand is approached
towards the forearm. Due to the low position of the styloid process of the radius, it has a
magnitude of 20-30o.
- Adduction, or ulnar abduction,is that movement in which the medial edge of the
hand isapproached to the forearm. It has a magnitude of 40o.
 - Circumduction results from the combination of the above movements the hand
describes an ellipsoid shape.

INTERCARPAL ARTICULATIONS
(Articulatio intercarpae)

Bone components:
They are represented by planee contact articular surfaces between the carpal bones. The
articulation of pisiform bone with pyramidal bone (Articulatio ossis pisiformis) isa
particularity, as it has strong ligaments.
Cartilaginous components: thin hyaline cartilage; it covers every contact articular
surface.
Connection means:
- Articular capsule is present in all the intercarpal articulations, and it is divided.
- Articular ligaments strengthen the fibrous capsule:
Palmar intercarpal ligaments (Ligamenta intercarpea palmarae) are situated on the
palmar surface of the bones.
Dorsal intercarpal ligaments (Ligamenta intercarpea dorsalia) areplanee short
ligaments located on the dorsal surface of the carpal bones.
- Interosseous intercarpal ligaments (Ligamenta intercarpea interossea) are
situated intraarticular.
- Pisometacarpal ligament (Ligamentum pisometacarpeum) is placed between the
pisiform bone and the basis of fifthmetacarpal bone.
- Pisohamate ligament (Ligamentum pisohamatum) is situated between the
pisiform bone and the hook of hamate bone.
Articular cavity:
- The synovial membrane covers the internal surface of the fibrous capsule, and is
sending extensions between the articulated bones.
Biomechanics: The articulations are planee, and with delicate sliding movements in all
directions. They give to the carpal bones a certain type of plasticity and adaptability during
movement of the hand.

MIDCARPAL ARTICULATION
(Articulatio medio-carpea)

The articulation is situated between the proximal and distal rows of the carpal bones,
with the notable exception of the pisiform bone, and has an articular line in the shape of
ahorizontal “S”.
Bone components:
- Inferior articular surfaces of the proximal carpal row.
- Superior articular surfaces of the distal carpal row.
Cartilaginous components: contact surfaces are covered by a thin hyaline cartilage.
Connection means:
The articular capsule is common with those of intercarpal articulations: lax and
strengthened by ligaments.
Ligaments:
- Radiate carpal ligament (Ligamentum carpi radiatum) isa strong ligament. It is
stretched on the palmar surface between the neck and the base of the capitate, scaphoid,
lunate, and pyramidal bones in the shape of “V”.
 - Collateral ligaments of the wrist joint also contribute to strengthening the
midcarpal articulation.
Articular cavity: the synovial membrane is common in the intermetacarpal articulations,
and is sending upward, and downward, extensions between the bones of the proximal and
distal rows.
Biomechanics: they aresimilar with the movements of an ellipsoid articulation, where
the cavity is formed by the superior carpal row,and biomechanically constitutes a functional
complex with the radiocarpal articulation. It completes the movements started in this
articulation, and is participating mostly at the backwards flexion of the hand where the
inferior row of the carpal bones moves dorsally.

CARPOMETACARPAL ARTICULATIONS
(Articulationes carpometacarpeae)

Due to the anatomical position, and articular biomechanics, the carpometacarpal

articulations divide into:
- Carpometacarpal joint of the thumb
- Carpometacarpal joints of the fingers II-V.

CARPOMETACARPAL JOINT OF THE THUMB

(Articulatio carpometacarpalis polecis)

It is a saddle articulation, and is also called trapezometacarpal articulation.

Bone components:
- Inferior surface of the trapezium bone; it is quadrilaterally shaped. It is concave
transversely, and convex from anterior to posterior.
- Articular surface on the base of first metacarpal bone is the inverse of the
aforementioned articular surface: convex transversely, and concave from anterior to posterior.
Cartilaginous components:
- Articular surfaces are covered by hyaline cartilage.
Connection means:
- Fibrous capsule in the shape of a sleeve; it inserts on the edge of the articular
surfaces of the contact bones, and it is more lax; allowing for broader movements. The
fibrous fascicles situated on the posterior and lateral surfaces serve in strengthening the
capsule.
Articular cavity:
- The synovial membrane covers the internal surface of the fibrous capsule, and inserts
on the edges of the articular cartilages.
Biomechanics: The two articular surfaces have the shape of a saddle; thus, realizing a
saddle joint. It is the most differentiated joint of the hand. Due to which, the thumb can
execute characteristicallyhuman movements, such as prehension. The joint has two main
axes; the anterior-posterior axis passes through the base of the first metacarpal bone, and
allows movements of abduction-adduction; the transverse axis crosses the trapezium bone,
and allows for movements of opposition and reposition.
- Abduction is the movement by which the thumb is moved away from the rest of the
fingers, and has a magnitude of 40o.
- Adduction is bringing the thumb near the planee of the hand, and towards the other
fingers.
- Opposition is the movement characteristic to human beings. Due to the flexion in the
articulation, the thumb leaves the hand planee, is directed to the middle of it, and is face-to-
face with the rest of the fingers. The magnitude of opposition allows the thumb to reach the
tip of the small finger.
- Reposition is the inverse movement to opposition, and is being realized by the
extension of the articulation; the thumb will be placed near the other fingers in the planee of
the hand.
- Circumduction of the thumb is made by combining the above movements.

CARPOMETACARPAL ARTICULATIONS OF THE FINGERS II-V

(Articulationes carpometacarpeae digitorum II-V)

Bone components:
- Inferior articular surfaces of the distal carpal row.
- Articular surfaces situated at the base of metacarpals II-V.
Cartilaginous components:
- Articular surfaces are covered by a thin hyaline cartilage.
Connection means:
- Common fibrous articular capsule inserts at the edge of the articular cartilages.
- Strengthening ligaments of the capsule are:
- Palmar carpometacarpal ligaments (Ligamenta carpometacarpalia palmaria).
- Interosseous carpometacarpal ligaments (Ligamenta carpometacarpalia
interossea).
- Dorsal carpometacarpal ligaments (Ligamenta carpometacarpalia dorsalia).
Articular cavity: the synovial membrane presents a distal extension of the synovial
membrane of the midcarpal articulation.
Biomechanics: They act as planee articulations, allow small sliding movements to the
metacarpal bones, and are modifying the shape of the palm. This isnecessary for grasping
planee or curved surfaces.

INTERMETACARPAL ARTICULATIONS
(Articulationes intermetacarpales)

Bone components:
- Are represented by a small contact surface. The sides of the base of metacarpal bones
II-V.
Cartilaginous components:
- Articular surfaces are covered by a thin layer of hyaline cartilage.
Connection means:
- Articular capsule – is common with the carpometacarpal articulations.
- Strengthening ligaments of the capsule are:
- Palmar ligaments (Ligamenta metacarpalia palmaria)
- Interosseous ligaments (Ligamenta metacarpalia interossea)
- Dorsal ligaments (Ligamenta metacarpalia dorsalia)
- Each ligament is stretched transversally between two adjacent bones.
Biomechanics: Intermetacarpal articulations are two planee joints. They allow small
sliding movements of the metacarpal bones during the individual movements of the fingers
II-V.

METACARPOPHALANGEAL ARTICULATIONS
(Articulationes metacarpophalangeales)
 Bone components:
- The round articular surfaces from the head of the metacarpal bones.
- The slightly concave surfaces from the base of the proximal phalanges.
Connection means:
- The fibrous articular capsule has the shape of a sleeve, and binds the extremities of the
bones.
The ligaments are thin, and they strengthen the articular capsule:
- Palmar ligaments (Ligamenta palmaria) are made up from strong, dense, fibers.
They are placed on the palmar surfaces of the articulations, and merge with the deep
transverse metacarpal ligament.
- Collateral ligaments (Ligamenta collateralia) are situated on the sides of the
articulations; between the rugosity of metacarpal head, and the marginal rugosity of the
proximal phalanges. They have the shape of a fan.
- Deep transverse metacarpal ligament (Ligamentum metacarpale transversum
profundum); it is placed more superficially on the palmar surface of the articulation,
between the base of the metacarpal bones II-V, and the interosseous spaces. It merges with
the articular capsule, and with the palmar ligaments. It prevents the metacarpal bones from
moving away.
Articular cavity of the proximal phalanx is deepened in the glenoid fibrocartilage,
which in some cases has a sesamoid bone.
The synovial membrane is fine, thin, and it covers individually each fibrous articular
capsule.
Biomechanics: They are ellipsoid articulations with flexion, and extension movements,
around a transverse axis placed through the head of the metacarpal bone. Also, they allow
movements of abduction and adduction around an anterior-posterior axis.
We mention that in this articulation, there can be executed only passive movements of
rotation of the fingers.
- Flexion has a magnitude of 90o
- Extension can be forced until hyperextension with 10-20o.
- Abduction, or moving the fingers away from eachother, is made with fingers in
extension. The magnitude of the abduction for fingers II-IV is 20o, and for the little finger,
50o. However, taking into account the abduction being executed in the carpometacarpal
articulation, the total abduction of the thumb will be 90o.
- Adduction, or the fingers closing in towards the planee of the hand, can be realized
until the fingers come in contact to each other. Placing the fingers before the planee of hand
allows forthe edge of fingertip II to come in contact with finger V.
- Circumduction results from the combination of the above movements, and isthe most
ample in the index finger.

INTERPHALANGEAL ARTICULATIONS
(Articulatio interphalangeales manus)

Each finger of the hand has two articulations: proximal and distal, with the exception of
the thumb, which has only one articulation.
Bone components:
- Phalanx trochlea situated proximal.
- Articular surface, slightly concave, and presenting a ridge oriented from anterior to
posterior.
Cartilaginous components:
- Contact articular surfaces are covered by a thin fibrocartilage.
 Connection means:
- The articular capsule is lax, especially posteriorly; it inserts on the edges of the
articular surfaces.
- Strengthening ligaments of the articular capsule are:
- Palmar ligament (Ligamentum palmare) situated on the palmar surface of the
articulation.
- Collateral ligaments (Ligamenta collateralia) stretched on the sides of the
articulations.
Articular cavity: the fibrous articular capsule is covered by a thin layer of synovial
membrane.
Biomechanics: The interphalangeal articulations are hinge joins that allow the flexion
and the extension of the phalanges around some transverse axes that cross the trochlea.
- Flexion in the proximal interphalangeal articulation is 90-120o, and in the distal
interphalangeal articulation is 90o.
- Extension in both articulations is 180o; in the thumb there can also be realized a
hyperextension of 15-20o.
Intoduceti foto cu rtg articulatie umar, cot, radiocarpiana
Eco – cot, radiocarpiana, interfalangiana
 MUSCLES OF THE UPPER LIMB
(Musculi membri superioris)

It represents the muscles of the pectoral arch, and of the free part of the upper limb. For
anatomical and functional reasons, they are divided in:
- Shoulder muscles.
- Arm muscles.
- Forearm muscles.
- Hand muscles.

SHOULDER MUSCLES

DELTOID MUSCLE
(Musculus deltoideus)

It is a thick, triangular-shaped, and convex muscle. Its base is on the pectoral arch,
and the tip is directed downwards towards the arm. It is placed superficially on the lateral
side of the shoulder, and is covered by the deltoid fascia (Fascia deltoidea), which sends
septa between the muscular fibers.
Parts:it is formed from three sets of muscular fibers:
- Clavicular fibers (Pars clavicularis), directed obliquely and vertically.
- Acromial fibers (Pars acromialis);
- Scapular fibers (Pars scapularis) directed obliquely and vertically.
The three sets of fibers merge in one strong tendon.
Origin:
- Anterior border of the lateral third of the clavicle, by short tendinous fibers.
- External border of the acromion, by three tendinous blades, placed on the edge of
the bone.
- Spine of scapula, through an aponeurotic blade.
Insertion:
- Through a flat, strong tendon on the deltoid tuberosity of the humerus.
Innervation:
- Axillary nerve, branch of the posterior cord of the brachial plexus (C5-C6)
Action:
- Maintains the arm in the shoulder articulation through its tone.
- Arm abductor up to the vertical position due to contraction of its three sets of
muscular fibers.
- Clavicular fibers are involved in internal rotation and flexion of the arm.
- Scapular fibers act in external rotation and extension of the arm up to 90o.

SUPRASPINATUS MUSCLE
(Musculus supraspinatus)

Supraspinatus muscle has a triangular pyramidal shape, placed in the supraspinatus

fossa of the scapula under the trapezius muscle.
Origin:
- In the medial two thirds of the supraspinatus fossa of the scapula.
- On the internal surface of the supraspinatus fascia that covers it.
The muscle tendon passes under acromioclavicular joint and coracoacromial ligament.
Insertion:
 - Superior surface of the greater tubercle of humerus.
Inervation:
- Suprascapular nerve, branch from the brachial plexus (C5,6).
Action:
- Arm abductor.
- Moving muscle of the glenohumeral joint.

INFRASPINATUS MUSCLE
(Musculus infraspinatus)

It is a thick triangular muscle that is situated deep in the infraspinatus fossa of the
scapula, under the trapezius and deltoid muscles, and is covered by infraspinatus fascia.
Origin:
- Bone surface of the infraspinatus fossa.
Insertion:
- Muscular fibers have an oblique and ascending trajectory, passing posteriorly from
the glenohumeral joint; it inserts on the middle surface of the greater tubercle of humerus.
Between the muscle tendon and bone surface, is the subtendinous bursa of infraspinatus
(Bursa musculi infraspinati subtendinea), which sometimes communicates with the
shoulder joint.
Inervation:
- Suprascapular nerve from the brachial plexus(C5,6)
Action:
- External rotation of the arm.
- Adduction of the arm.

TERES MINOR MUSCLE

(Musculus teres minor)

It is a broad, elongated muscle, which is situated dorsally from the glenohumeral joint.
Origin:
- From the superior two thirds of the lateral border, from the dorsal surface of
scapula.
- Infraspinatus fascia.
Trajectory:
- The muscular fibers have a laterally-oblique trajectory, toward humerus.
Insertion:
- Inferior surface of the greater tubercle of humerus.
Innervation
- Axillary nerve, branch of the posterior cord of the brachial plexus (C5,6)
Action:
- External rotation of the arm.
- Adduction of the arm.

TERES MAJOR MUSCLE

(Musculus teres major)

Elongated, flat muscle, placed underneath teres minor muscle.

Origin:
 - On the dorsal surface of the scapula, on a triangular area situated above inferior
angle.
- Infraspinatus fossa.
- Internal surface of the infraspinatus fascia.
Trajectory:
- The muscular fibers are directed upward and lateralward, passing on the medial
surface of the glenohumeral joint.
Insertion:
- Through a broad tendon on the creast of the lesser tubercle.
Innervation:
- Thoracodorsal nerve, branch of the brachial plexus (C6,7)
- Subscapular nerve.
Action:
- Internal rotation of the arm.
- Adduction of the arm.
Mention:
- The long head of triceps brachii muscle separates the tendon of teres minor muscle
from teres major muscle, and is delimiting along with humerus bone two spaces: medially,
the triangular space, and laterally, the quadrilateral space that will be described in the
chapters regarding topographic anatomy.

SUBSCAPULARIS MUSCLE
(Musculus subscapularis)

It is a triangular muscle placed on the costal surface of scapula, with muscular fibers
directed toward the superior extremity of humerus, andis passing ahead of the glenohumeral
joint.
Origin:
- Muscular lines from the costal surface of scapula and from interlinear bone
surfaces of the subscapular fossa.
Insertion:
- Through a broad and thick tendon on the lesser tubercle of humerus.
Innervation:
- Subscapular neve, branch of the brachial plexus (C6,7).
Action:
- Internal rotation of the arm.
- Adduction of the arm.

ARM MUSCLES

These long muscles are extended around the humerus, and form two muscular groups:
- Anterior or flexors group.
- Posterior or extensors group.

ANTERIOR OR FLEXORS GROUP

They are situated on the anterior surface of humerus, ahead of the medial and lateral
septa of the arm, and in two planees:
- Superficial planee represented by:
- Biceps brachii muscle.
 - Profound planee consists of:
- Coracobrachial muscle.
- Brachial muscle.
BICEPS BRACHII MUSCLE
(Musculus biceps brachii)

It is a long, fusiform muscle that islocated superficially.

Parts:
Long head (Caput longum); is longer, and more voluminous. It is situated laterally
from the short head. It crosses the glenohumeral joint, wrapped in a synovial sheath (Vagina
synovialis intertubercularis), and is also crossing the intertubercular groove of humerus. In
the middle third of the arm it merges with the short head of biceps.
Short head (Caput breve); it descends obliquely ahead of coracobrachialis muscle.
Trajectory:
- The united muscular body has a descending trajectory toward the forearm.
Origin:
- Long head originates on the supraglenoid tubercle of the scapula through a long,
cylindrical tendon, and also is arising from the labrum glenoidale.
- Short head originates on the coracoid process, and has a strong tendon common
with that of coracobrachialis muscle.
Insertion:
- Radial tuberosity, through a large, strong tendon.
- Aponeurotic expansion of the biceps tendon (Aponeurosis musculi bicipitis
brachii), with an oblique, descending trajectory that medially is the same with the fascia of
the forearm.
Innervation:
- Musculocutaneous nerve, from the lateral cord of brachial plexus (C5,6)
Action:
- Strong flexor of the forearm to arm.
- Supinator if the forearm is in pronation.
- Long head: abductor of the arm and stabilizes the shoulder articulation.
- Short head: adductor of the arm.

CORACOBRACHIALIS MUSCLE
(Musculus coracobrachialis)

It is a long muscle that is situated on the superior-medial side of the arm.

Trajectory: muscular fibers have an oblique, latero-inferior trajectory.
Origin:
- Coracoid process of scapula, through a common tendon with the short head of
biceps brachii muscle.
Insertion:
- The middle third of the anterior-medial surface of humerus, with a short tendon.
- Medial intermuscular septum of the arm.
Innervation:
- Musculocutaneous nerve (C5,6).
Action:
- Adduction of the arm.
- Flexion of the arm.
 BRACHIALIS MUSCLE
(Musculus brachialis)

Broad muscle, placed in the anterior-inferior part of humerus ahead of the articulation
of the elbow.
Origin:
- Anterior border, anterior-medial, and anterior-lateral surfaces of the humerus,
under the insertion of deltoid muscle and coracobrachialis muscle.
Insertion:
- Ulnar tuberosity, through a large tendon.
Innervation.
- Musculocutaneous nerve.
Action
- The strongest flexor of forearm to arm.
- Tensor of elbow articular capsule.

POSTERIOR OR EXTENSORS GROUP

TRICEPS BRACHII MUSCLE

(Musculus triceps brachii)

Triceps brachii muscle is situated on the posterior surface of humerus; it is made of

three distinct parts:
Parts:
- Long head (Caput longum) has a downward trajectory; it crosses the interstitial
passage between the teres major and teres minor, and contributes to delimitating the medial
and lateral axillary spaces (Hiatus axillaris medialis et lateralis). (Structures described in
the topographic anatomy chapters).
- Medial head (Caput mediale) with muscular fibers directed obliquely, downward
and laterally.
- Lateral head (Caput laterale) with an oblique, downward and medial trajectory,
being situated above the radial nerve groove.
- The medial and lateral heads are the same with the tendon of the long head in the
middle third of the arm.
Origin:
- Long head, infraglenoid tubercle and on the superior part of the axillary (lateral)
border of the scapula.
- Medial head, posterior surface of humerus, distally from the radial nerve groove.
- Lateral head:
- Posterior surface of the medial intermuscular septum.
- Posterior surface of humerus, above radial nerve groove.
Insertion:
- On the olecranon, through the common, strong, flattened tendon. Between the
bone and the triceps brachii tendon is interposed the subtendinous bursa of triceps brachii
(Bursa subtendinea musculi triceps brachii).
Innervation:
- Radial nerve, branch of the brachial plexus (C6,7,8).
Action:
- Forearm extensor.
- The long head acts as arm extensor.
 FOREARM MUSCLES
(Musculi antebrachii)

The forearm muscles divided by their action and by their positioning toward the bone
skeleton in two groups, anterior group and posterior group.

ANTERIOR GROUP
SUPERFICIAL PLANEE

PRONATOR TERES MUSCLE

(Musculus pronator teres)

It is situated the most laterally, and it has two heads of origin.

Parts:
- Humeral head (Caput humerale), more voluminous.
- Ulnar head (Caput ulnare).
Origin:
- Humeral head (Caput humerale):
- Anterior surface of the medial epicondyle of humerus.
- Ulnar head (Caput ulnare)
- Coronoid process of ulna.
Trajectory: the two united heads delimit a space, a hole for the passing of the median nerve.
The muscular fibers have a diagonally oblique, downward and lateral direction, that heads
towards the middle third of the forearm.
Insertion:
- Pronator tuberosity from the lateral surface of radius.
Action:
- Pronator of the forearm (main function).
- Flexes the forearm on arm.

FLEXOR CARPI RADIALIS MUSCLE

(Musculus flexor carpi radialis)

Fusiform muscle, bipennated, placed medially from the pronator teres muscle.
Origin:
- Anterior surface of the medial epicondyle of humerus.
Trajectory: it has an oblique, downward and lateral trajecory. It has a long tendon, which
passes under flexor retinaculum through the carpal tunnel.
Insertion:
- Anterior surface of the base of the second metacarpal bone.
Innervation:
- Median nerve (C6,7)
Action:
- Flexes the hand on forearm.
- Abductor of hand on forearm.
- Weak flexor of forearm on arm and weak pronator.

PALMARIS LONGUS MUSCLE

(Musculus palmaris longus)
 It is also called the small palmaris, and is situated medially from the flexor carpi radialis
muscle (an inconstantly present muscle).
Origin:
- Anterior surface of the medial epicondyle of humerus.
The short muscular part in the inferior half of the forearm continues with a long, thin
and flat tendon.
Insertion:
- On palmar aponeurosis.
Inervation:
- Median nerve (C6,7,8).
Action:
- Weak flexor of the arm to forearm.

FLEXOR CARPI ULNARIS MUSCLE

(Musculus flexor carpi ulnaris)

It is situated on the median side of the forearm stretched between the medial epicondyle
of the humerus and the pisiform bone, and has two heads of origin.
Parts:
- Humeral head (Caput humerale)
- Ulnar head (Caput ulnare)
Origin:
- Humeral head (Caput humerale):
- On medial epicondyle of humerus.
- Ulnar head (Caput ulnare)
- On medial border of olecranon
- On the superior two thirds of the posterior edge of ulna.
Trajectory: the two heads unite through a fibrous arch that delimits an osteofibrous
tunnel for the passing of the ulnar nerve. The muscular fibers unite at the middle of the
forearm through a long tendon.
Insertion:
- On the pisiform bone through two prolongations; the pisihamate, and the
pisimetacarpal ligaments. These end on the hook of the hamate bone and on the base of the
fifth metacarpal bone.
Innervation:
- Ulnar nerve.
Action:
- Flexor of the hand on forearm.
- Adductor of the hand.

FLEXOR DIGITORUM SUPERFICIALIS MUSCLE

(Musculus flexor digitorum superficialis)

It is a broad muscle that is situated beneath the described superficial muscles.

Parts: It has two origin heads:
- Humeroulnar head (Caput humeroulnare) more voluminous with a long linear
origin.
- Radial head (Caput radiale).
Origin:
 - Humeroulnar head:
- Medial epicondyle of humerus.
- Radial head:
- On the superior part of the anterior border of radius, between radial tuberosity and
pronator tuberosity.
Trajectory:
- The two heads unite form a fibrous arch, underneath which passes the median
nerve and the ulnar artery.
- The muscular fibers, in the middle third of the forearm, continue with four long
flattened tendons that pass beneath the flexor retinaculum through the carpal tunnel in two
overlapping planees:
- Superficial planee: pass the tendons for the third and fourth fingers.
- Profound planee: contains the tendons for fingers two and five. At the level of the
palm, the tendons take a divergent trajectory, and at the level of proximal phalanges, they
bifurcate in two strips (perforated tendon) allowing the passing of the tendons of the flexor
digitorum profundus muscle.
Insertion:
- The two strips pass on the posterior surface of the proximal phalanges, and after a
twisting spiral, they insert on the head and edges of the middle phalanx of the fingers II-V.
Innervation:
- Median nerve (C7,8; T1)
Action:
- Flexor of the middle and proximal phalanges on the hand.
- Flexor of the hand on forearm.
- Flexor of the forearm on arm.

PROFOUND PLANEE

FLEXOR DIGITORUM PROFUNDUS MUSCLE

(Musculus flexor digitorum profundus)

It is situated deep, on the medial side of the forearm.

Origin:
- From the superior two thirds of the anterior and medial surfaces of ulna.
- Medial half of the anterior surface of the interosseous membrane in its middle
third.
Trajectory: the muscular part, in the inferior third of the forearm, continues with four
tendons that pass under the flexor retinaculum through the carpal tunnel, towards the palm,
and under the tendons of flexor digitorum superficialis muscle.
Insertion:
- The muscle tendons, after they pass through the holes of the tendons of flexor
digitorum superficialis muscle (perforated tendon), insert on the base of the distal phalanges
of the fingers II-V.
Innervation:
- The medial part of the muscle, for the fourth and fifth fingers is innervated by the
ulnar nerve (C8, T1).
- Median nerve (C7,8 T1) innervates the lateral part of the muscle, for the second
and third fingers.
Action:
- Flexor of all phalanges.
 - Flexor of the fingers on the hand.
- Flexor of the hand on forearm.
- Adductor of the hand.
FLEXOR POLLICIS LONGUS MUSCLE
(Musculus flexor pollicis longus)

It is a long muscle, situated deep on the lateral side of the forearm, on the same planee
with the flexor digitorum profundus muscle.
Origin:
- Anterior surface of radius, between radial tuberosity and the superior border of the
pronator quadratus muscle.
- Lateral part of the adjacent interosseous membrane.
Trajectory: the muscular body continues distally with a long tendon that passes
underneath the flexor retinaculum, through carpal tunnel, and towards the thumb.
Insertion:
- The base of the distal phalanx of the thumb.
Innervation:
- Anterior interosseous nerve, branch of the median nerve (C8, T1).
Action:
- Flexor of the distal and proximal phalanges of the thumb.
- Flexor of the thumb on the first metacarpal bone.

PRONATOR QUADRATUS MUSCLE

(Musculus pronator quadratus)

It is a quadrilateral muscle that is situated in the most profound part of the distal part
of the forearm.
Origin:
- On the distal fourth of the anterior surface of the body of ulna. The muscular fibers
are directed transversally.
Insertion:
- On the distal fourth of the anterior surface of the body of radius.
Innervation:
- Anterior interosseous nerve, branch of the median nerve (C8, T1)
Action:
- Pronator of the forearm.
- Pronator of the hand.

POSTERIOR OR EXTENSORS GROUPSUPERFICIAL PLANEE

BRACHIORADIALIS MUSCLE
(Musculus brachioradialis)

It is placed superficially on the lateral side of the forearm; functionally, it also belongs
to the flexors group, and is also called “the long supinator”.
Origin:
- Lateral border of humerus, above the lateral epicondyle.
The muscular fibers converge at the middle of the forearm in a narrow and flat tendon.
Insertion:
- The lateral surface of the base of the styloid process of radius.
 Innervation:
- Radial nerve (C5,6).
Action:
- Flexion of the forearm on arm.
- In the pronation position of the forearm it executes the supination movement.
- In the supination position of the forearm, it executes the pronation movement.

EXTENSOR CARPI RADIALIS LONGUS MUSCLE

(Musculus extensor carpi radialis longus)

It is partially covered by brachioradialis muscle.

Origin:
- The distal third of the lateral border of humerus.
- The lateral epicondyle of humerus.
Trajectory: the muscular body in the middle of the forearm continues with a flat tendon,
descends through the lateral groove situated on the posterior surface of the distal extremity of
radius; it is crossing with the tendons of the abductor pollicis longus, extensor pollicis brevis
and longus muscles, being situated beneath them.
Insertion: on the dorsal surface of the base of the second metacarpal bone.
Innervation:
- Radial nerve (C6,7)
Action:
- Extensor of the hand on forearm.
- Abductor of the hand.
- It contributes to the flexion of the forearm on arm.

EXTENSOR CARPI RADIALIS BREVIS MUSCLE

(Musculus extensor carpi radialis brevis)

It is shorter and partially covered by the extensor carpi radialis longus muscle.
Origin:
- Lateral epicondyle of humerus.
- Lateral intermuscular septum of arm.
Trajectory: the tendon passes parallely with the tendon of the extensor carpi radialis
longus muscle.
Insertion:
- Dorsal surface of the base of the third metacarpal bone.
Innervation:
- Radial nerve (C6,7).
Action:
- Extensor of the hand on forearm.
- Abductor of the hand.

EXTENSOR DIGITORUM MUSCLE

(Musculus extensor digitorum)

It is situated on the lateral side of the forearm; the muscular body continues with four
tendons, which on the dorsal surface of the hand, are connected through a series of oblique
fibrous strips called intertendinous connections (Connexus intertendineus).
Origin:
 - Lateral epicondyle of humerus.
Trajectory: the tendons pass under flexor retinaculum, and then diverge towards fingers
II-V. On the dorsal surface of hand, near the metacarpophalangeal articulations, the tendons
are united through a series of oblique fibrous bands called intertendinous connections
(Connexus intertendineus).Each tendon forms a triangular tendonous expansion, which
divides in three fascicles: middle- which attaches to the base of the middle phalanx; and the
two lateral fascicleswhich cross the dorsal surface of the proximal interphalangeal
articulation, and then unite on the dorsal surface of the middle phalanx.Along with the fibrous
expansions of the interosseous and lumbrical muscles, it contributes in creating the dorsal
aponeurosis of the fingers.
Insertion:
- On the base of the distal phalanx.
Innervation:
- The posterior interosseous nerve, branch of the radial nerve (C7,8)
Action:
- Extensor of the phalanges.
- Extensor of the fingers on hand.
- Extensor of the hand on forearm.

EXTENSOR DIGITI MINIMI MUSCLE

(Musculus extensor digiti minimi)

It is a thin muscle, being placed medially from the extensor digitorum muscle, and its
muscular body merges with the body of the extensor digitorum muscle.
It has the origin on the lateral epicondyle of humerus. Its flat tendon is near the
metacarpophalangian articulation, and merges with the tendon of the extensor of the last
finger; together, they fix on the last two phalanges.
It is innervated by the radial nerve, and it executes the extension of the little finger.

EXTENSOR CARPI ULNARIS MUSCLE

(Musculus extensor carpi ulnaris)

Situated on the medial side of the forearm, it has two origin heads:
Origin:
- Humeral head (Caput humerale):
- Lateral epicondyle
- Ulnar head (Caput ulnare):
- On the superior and middle third of the posterior border of ulna.
Trajectory:the muscular fibers converge to a short tendon that passes underneath the
flexor retinaculum.
Insertion:
- On the medial side of the base of fifth metacarpal bone.
- Fifth metacarpal bone tuberosity.
Innervation:
- Posterior interosseous nerve, branch of the radial nerve (C7,8).
Action:
- Extensor of the hand.
- Adductor of the hand.

ANCONEUS MUSCLE
 (Musculus anconeus)

It is a small, triangular muscle, and is situated on the dorsal surface of the elbow in the
continuation of the triceps brachii muscle.
Origin:
- Posterior surface of the lateral epicondyle of humerus.
Trajectory: the muscular fibers have an oblique, divergent, downward and medialward
trajectory toward ulna.
Insertion:
- The lateral surface of the olecranon and the posterior-superior border of ulna.
Innervation:
- Radial nerve (C7,8)
Action:
- Extensor of the forearm.

DEEP PLANEE

SUPINATOR MUSCLE
(Musculus supinator)

It is situated deep in the superior-lateral part of the forearm, and is covered by the
muscles of the superficial planee.
Parts:
- The muscular fibers are distributed on two planees:
- Superficial planee;
- Profound planee.
Origin:
- Superficial planee:
- On the lateral epicondyle of humerus.
- On the collateral ligament, lateral of the elbow joint.
- On the annular ligament of the radius.
- Deep planee:
- On the supinator crest of ulna.
Trajectory:
- The muscular fibers have an oblique, medial to lateral, trajectory towards the
radius, and are wrapping around it.
- Between the two muscular planees there is a fibromuscular passage, the supinator
channel, through which passes the profound (motor) branch of the radial nerve.
Insertion:
- Lateral surface and anterior border of radius, between the neck of radius and
pronator tuberosity.
Innervation:
- Profound branch of the radial nerve (C5,6)
Action:
- Main supinator of the forearm.

ABDUCTOR POLLICIS LONGUS MUSCLE

(Musculus abductor pollicis longus)

It occupies the lateral side of the deep planee.

 Origin:
- On the distal part of the posterior surface of ulna, radius, and interosseous
membrane.
Trajectory: the muscular fibers are directed obliquely downwards and laterally. They
pass under the extensor retinaculum, above the thumb, and cross with the tendons of the carpi
radialis extensors muscles to attach to the tendon of the extensor pollicis brevis muscle.
Insertion:
- On the lateral surface of the base of the first metacarpal bone.
Innervation:
- Radial nerve (C7,8)
Action:
- Abductor of the thumb.
- Abductor of the hand.

EXTENSOR POLLICIS BREVIS MUSCLE

(Musculus extensor pollicis brevis)

It is situated downwards and medially from the abductor pollicis longus muscle.
Origin:
- Posterior surface of radius.
- Posterior surface of the interosseous membrane.
Trajectory: the muscle has an oblique, middle-lateral trajectory, the tendinous part
passing parallel with the abductor pollicis longus muscle under the extensor retinaculum.
Insertion:
- On the dorsal surface of the base of the proximal phalanx of the thumb.
Innervation:
- Posterior interosseous nerve, branch of the radial nerve (C7,8).
Action:
- Extensor of the thumb.
- Abductor of the thumb.

EXTENSOR POLLICIS LONGUS MUSCLE

(Musculus extensor pollicis longus)

It is placed medially and distally from the extensor pollicis brevis muscle.

Origin:
- The middle third of the posterior surface of ulna.
- The dorsal surface of the adjacent interosseous membrane.
Trajectory:
- The muscular fibers converge into a long tendon, are directed inferiorly and
laterally, andpass under the extensor retinaculum toward the thumb; it iscriss-crossing with
the tendons of the carpi radialis extensors muscles.
- “Anatomical snuff box” is a triangular pit on the dorsal-lateral side of the hand,
above the thumb. Laterally, it is delimited by the tendons of abductor pollicis longus,and
extensor pollicis brevis muscles, respectively; medially, it is delimited by the tendon of
extensor pollicis longus muscle, and in its depth passes the radial artery and the tendons of
carpi radialis extensors muscles.
Insertion:
- Dorsal surface of the base of the distal phalanx of the thumb.
 Innervation:
- Posterior interosseous nerve, branch of the radial nerve (C7,8)
Action:
- Extensor of the distal and proximal phalanx of the thumb.
- Extensor and abductor of the hand.

EXTENSOR INDICIS MUSCLE

(Musculus extensor indicis)

It is situated deep, inferior and medial from the extensor pollicis longus.
Origin:
- On the inferior half of the dorsal surface of ulna.
- On the dorsal surface of the adjacent interosseous membrane.
Trajectory: the tendon descends under the extensor retinaculum, and on the dorsal
surface of the hand, it merges with the tendon of the extensor of the fingersfor the index
finger.
Insertion:
- On the dorsal aponeurosis of the index, along with the tendon of the extensor of
the third finger.
Innervation:
- Dorsal interosseous nerve, branch of the radial nerve (C7,8)
Action:
- The independent extension of the index finger.

THENAR MUSCLES
(Musculi thenarii)

ABDUCTOR POLLICIS BREVIS MUSCLE

(Musculus abductor pollicis brevis)

It is situated the most superficial of the thenar muscles.

Origin:
- Through muscular fibers from:
- The tubercle of scaphoid bone
- The tubercle of trapezium bone.
- Extensor retinaculum.
Insertion:
- Through a short tendon on:
- Lateral surface of the base of the proximal phalanx.
- The lateral sesamoid bone of the thumb.
Innervation:
- Median nerve (T1).
Action:
- Abductor of the thumb.

FLEXOR POLLICIS BREVIS MUSCLE

(Musculus flexor pollicis brevis)

Short muscle, placed medially, it has two muscular fascicles.

Parts:
 - Superficial fascicle;
- Profound fascicle.
Origin:
- Superficial fascicle:
- Flexor retinaculum (distal border)
- The tubercle of trapezium bone.
- Profound fascicle:
- Palmar surface of the trapezoid bone.
- Palmar surface of the trapezium bone.
- Palmar surface of the capitate bone.
Trajectory: the two fascicles delimit a longitudinal groove for the tendon of the flexor
pollicis longus muscle.
Insertion:
- The lateral surface of the base of the proximal phalanx of the thumb.
- The medial and lateral sesamoid bones of the thumb.
Innervation:
- Median nerve (T1)
- The branch of the ulnar nerve (C8, T1).
Action:
- Flexor of the thumb.
- Involved in the opposition movement of the thumb.

OPPONENS POLLICIS MUSCLE

(Musculus opponens pollicis)

It is a short muscle, and is placed laterally from the flexor pollicis brevis muscle. It is
covered by the abductor pollicis muscle.
Origin:
- On the flexor retinaculum.
- On the tubercle of trapezium bone.
Insertion:
- Anterior border and the lateral surface of the first metacarpal bone.
Innervation:
- Median nerve (T1).
Action:
- The opposition of the thumb on hand.

ADDUCTOR POLLICIS MUSCLE

(Musculus adductor pollicis)

The origin and the muscular body are situated deep in the mesothenar. Only its terminal
part is in the thenar compartment; functionally it belongs to the thumb.
Parts:It has two heads:
- Oblique head (Caput obliquum), or carpal head, is placed more superficially.
- Transverse head (Caput transversum), or metacarpal head, is placed deep.
Origin:
- Oblique head (Caput obliquum), or carpal head, is placed more superficially.
- On the palmar surfaces of trapezoid and capitate bones.
- On the base of the second, third and fourth metacarpal bones.
- Transverse head (Caput transversum), or metacarpal head, is situated deep.
 - The palmar surface of second and third metacarpal bones.
Trajectory: the two muscular heads unite and converge toward metacarpophalangian
articulation of the thumb, and cover the first two interosseous spaces of the metacarpal bones.
Insertion:
- The medial surface of the base of the proximal phalanx of the thumb.
- The medial sesamoid bone.
Innervation:
- The profound branch of the ulnar nerve (C8, T1).
Action:
- Adduction of the thumb directed toward the axis of the hand.
- Involved in the opposition movement of the thumb.

HYPOTHENAR MUSCLES
(Musculi hypothenaris)

PALMARIS BREVIS MUSCLE

(Musculus palmaris brevis)

Small muscle situated in the subcutaneous tissue of the hypothenar.

Origin:
- The medial border of the palmar aponeurosis.
- Flexor retinaculum.
Insertion:
- On the skin of the medial edge of the hand.
Innervation:
- Ulnar nerve.
Action:
- Folds the skin of the hypothenar eminence.

ABDUCTOR DIGITI MINIMI MUSCLE

(Musculus abductor digiti minimi)

It is situated superficially on the medial side of the hypothenar.

Origin:
- Pisiform bone.
- Pisohamate and pisometacarpal ligaments.
- Flexor retinaculum.
Insertion:
- The medial surface of the base of the proximal phalanx of the little finger.
Innervation:
- Profound branch of the ulnar nerve (T1).
Action:
- Abductor of the little finger, toward the axis of the hand.

FLEXOR DIGITI MINIMI BREVIS MUSCLE

(Musculus flexor digiti minimi brevis)

It is placed laterally from the abductor digiti minimi muscle, in the same planee.
Origin:
- Flexor retinaculum.
 - The hook of the hamate bone.
Insertion:
- The base of the proximal phalanx of the little finger.
Innervation:
- The profound branch of the ulnar nerve (T1).
Action:
- Flexion of the little finger.

OPPONENS DIGITI MINIMI MUSCLE

(Musculus opponens digiti minimi)

Situated deep, covered by the abductor digiti minimii muscle.

Origin:
- Flexor retinaculum.
- The hook of the hamate bone.
Insertion:
- On the two distal thirds of the medial surface of the fifth metacarpal bone.
Innervation:
- Ulnar nerve.
Action:
- It executes the opposition of the fifth finger.

MESOTHENAR MUSCLES

LUMBRICAL MUSCLES
(Musculi lumbricales)

It consists of four small, cylindrical muscles, for the fingers II-V; resembling in shape
with an earth worm, hence the name. They attach to the tendons of the flexor digitorum
profundus muscle.
Parts:
- The first and the second have only one head of origin.
- The third and fourth muscles have two heads of origin.
Origin:
- The first and second muscle, on the lateral edge of the tendon of flexor digitorum
profundus muscle, are destined for the index and middle finger.
- The third and fourth lumbrical muscles emerge with two heads of origin from the
adjacent surfaces of the tendons of the flexor digitorum profundus muscle:
- The third lumbrical muscle from the tendon is for the middle and ring fingers.
- The fourth lumbrical muscle from the tendon is for the ring and little fingers.
Trajectory: the muscular fibers continue with a short tendon which has an oblique
lateral trajectory, and laterally bypasses the metacarpophalangeal articulation of the
respective fingers.
Insertion:
- Through a fibrous expansion on the dorsal aponeurosis of the correspondent
finger.
Innervation:
- The first and second lumbrical muscles by median nerve (T1).
- The third and fourth lumbrical muscles by ulnar nerve (T1).
Action:
 - Flexor of the proximal phalanx of the hand in the metacarpophalangeal
articulation.
- Extensor of the middle and distal phalanx in the interphalangeal articulations.

PALMAR INTEROSSEI MUSCLES

(Musculi interossei palmares)

They are three muscles occupying the distal half of the last three metacarpal
interosseous spaces, and have a palmar position.
Origin:
- First; from the medial surface of the third metacarpal bone.
- Second; from the lateral surface of the fourth metacarpal bone.
- Third; from the lateral surface of the fifth metacarpal bone.
Trajectory:
The short tendons twist around the respective metacarpophalangeal articulations.
Insertion:
- First muscle on the medial surface of the proximal phalanx of the index finger.
- Second muscle on the lateral surface of the proximal phalanx of the ring finger.
- Third muscle on the lateral surface of the proximal phalanx of the little finger.
Mention:
- The middle finger has no palmar interossei muscle.
Innervation:
- The profound branch of the ulnar nerve (T1).
Action:
- The adduction of the fingers II, IV and V toward the axis of the hand, toward
middle finger.
- The flexion of the fingers II, IV and V in the metacarpophalangeal articulation.

DORSAL INTEROSSEI MUSCLES

(Musculi interossei dorsales)

Are four elongated muscles, more voluminous than the palmar ones, and they occupy
the intermetacarpal interosseous spaces; are situated in the dorsal part having two heads of
origin.
Origin:
- First muscle on the adjacent surfaces of the bodies of the first and second
metacarpal bones.
- Second muscle on the adjacent surfaces of the bodies of the second and third
metacarpal bones.
- Third muscle on the adjacent surfaces of the bodies of the third and fourth
metacarpal bones.
- Fourth muscle on the adjacent surfaces of the bodies of the fourth and fifth
metacarpal bones.
Insertion:
- On the base of the proximal phalanx.
- On the dorsal aponeurosis of the fingers, as follows:
- First muscle on the lateral surface of the index finger.
- Second muscle on the lateral surface of the middle finger.
- Third muscle on the medial surface of the middle finger.
- Fourth muscle on the medial surface of the ring finger.
 Innervation:
- Profound branch of the ulnar nerve (T1).
Action:
- The third finger has two dorsal interosseous muscles that act antagonistically, so
the middle finger remains in place both in the adduction performed by the palmar interossei
muscles, and also during the action of the dorsal interossei muscles.
- The abduction of the second and fourth fingers is towards the axis of the hand that
passes through the middle metacarpal bone and middle finger.
- Flexor of the proximal phalanx.
- Extensor of the middle and distal phalanges.
- Act synergistic with the lumbrical muscles of the fingers II, III and IV.
Foto cu Eco : supraspinos, deltoid, biceps caput longi, biceps, tendoane flexori , extensori
mana,
 FIBROCONNECTIVE FORMATIONS OF THE UPPER LIMB

They are represented by the fasciae and fibrous septa of the upper limb, which together
with the boney skeleton, delimit osteofibrous compartments for the muscular groups and
connective annexes. Also included in this category are the synovial sheaths, especially
prominant at the level of the hand and fingers, which serve the role of containing the tendons.

SHOULDER FASCIAE

The thick deltoid fascia covers the external surface of the deltoid muscle. It adheres to
the muscle due to the numerous connective interfascicular septa that penetrate inside the
deltoid muscle. Anteriorly, it continues with the pectoral fascia, and posteriorly, with the
infraspinatus muscle fascia.
The periscapular fascia covers the muscles that have the origin on the scapula, and is
dividedin the supraspinatus fascia, infraspinatus fascia, and subscapular fascia. Along with
the corresponding skeleton planee, it forms osteofibrous compartments for these muscles.
The axillary fascia, situated in the base of the axilla, adheres to the subcutaneous tissue,
and sustains the content of the arm pit. For this reason, it was called “Gerdy suspensor
ligament of the axilla”. It is formed from the fusion of the pectoral fascia and the
clavipectoral fascia at the free edge of the pectoralis major muscle; it passes over the axilla
and continues in the latissimus dorsi fascia.

ARM FASCIA
(Fascia brachii)

It continues the shoulder fasciae, and covers the arm muscles. On the anterior side, it is
thinner than on the posterior. It sends in the profoundness of the region two fibrous septae,
which are perforated in many places by vessels and nerves. Together with the humeral body,
they delimit two compartments; the anterior and posterior compartments for the two muscular
groups. These are:
Lateral intermuscular septum of the arm (Septum intermusculare brachii laterale); it
inserts on the crest of the greater tubercle, and the lateral border and lateral epicondyle of
humerus.
Medial intermuscular septum of the arm (Septum intermusculare brachii mediale); it
is stronger. It begins from the medial part of the fascia, and inserts on the crest of the lesser
tubercle, and the medial border and medial epicondyle of humerus.

FOREARM FASCIA
(Fascia antebrachii)

It has the shape of a cylindrical fibrous sheath, is thicker posteriorly, and is placed in
continuation of the arm fascia. It covers the forearm muscles, and is usually fixed on the
dorsal border of ulna. In the superior part of the forearm, from its profound surface, originate
some fibers of the superficial flexors and extensors of the forearm. In the superior and
internal part, it is fortified by the aponeurotic expansion of the biceps brachii muscle. It sends
profoundlya lateral intermuscular septum, which fixates on the posterior border of the radius.
Thus, it is separating the anterior group of forearm muscles from the posterior group of
forearm muscles. Due to the fascia being inserted directly on the ulna, most of the times the
muscular septum is missing, or is underdeveloped.
 At the level of the wrist, the forearm fascia participates in forming a strong transverse
fibrous system; represented by the retinacula, or circular ligaments, which serve to maintain
the tendons of the flexor and extensor muscles that come in contact with the bone during
movement.
- Flexor retinaculum (Retinaculum flexorum), or the anterior annular ligament, is a
large formation made up of superficial and profound fibers that are arranged transversally
between the two eminences of the carpus. Thus the carpal groove transforms into a fibrous
tunnel called the carpal tunnel (Canalis carpi) through which pass the tendons of the flexor
muscles from the forearm to the hand.
- Extensor retinaculum (Retinaculum extensorum), or the posterior annular
ligament, has an oblique, downward and medial, position. It completes the boney grooves
from the inferior extremity of radius, and is sending vertical septae to these. Thus, there are
formed six compartments, or osteofibrous tunnels, through which pass the extensor muscles
of the hand. (Described in the topographic anatomy chapters.)

FIBROCONNECTIVE FORMATIONS OF THE HAND

Palmar aponeurosis (Aponevrosis palmaris) is a strong fibrous blade that is placed

superficially in the center of the palm, and covers the muscles, vessels, and nerves. Thus, it
serves a protective role. It has a triangular shape with the tip directed towards the tendon of
palmaris brevis muscle, and with the basis directed towards the base of the last four fingers. It
is made of longitudinal fibers that are radiating towards the base of the fingers, and the more
profound transverse fibers.
- Longitudinal fibers (Fasciculi longitudinali) condense in front of the tendons of
the flexor muscles, forming four pre-tendinous bands. These are united through thin,
longitudinal intertendinous strips. At the base of the fingers, each pretendinous band detaches
in two strips that encircle the base of the fingers,and insert on the dorsal surface of the first
phalanx.
- The transverse fibers (Fasciculi transversi) condense in the inferior part of the
palm in three transverse arches placed in the same row. Inferiorly from these, at the level of
the metacarpophalangeal articulations, a new agglomerate of the transverse fibers forms the
superficial transverse metacarpal ligament (Ligamentum metacarporum transversum
superficiale or Ligamentum natatorium), which is stretched between the second and fifth
metacarpophalangeal articulations. Between these two rows of arches, corresponding to
interdigital spaces II-III-IV, there are formed three spaces through which pass the tendons of
lumbrical muscles and neurovascular bundles of the fingers.
From the profound surface of the palmar aponeurosis detach:
- Medial palmar septum; from the medial edge of the palmar aponeurosis to the
anterior border of the fifth metacarpal bone. It separates the hypothenar compartment.
- Lateral palmar septum; from the lateral edge of the aponeurosis to the anterior
border of the third metacarpal bone. It delimits the thenar compartment.
The superficial fascia of the palm is represented by thin sheaths that will continue the
palmar aponeurosis, cover the thenar and hypothenar muscles, and fixate on the edges of the
first and fifth metacarpal bones.
The profound fascia of the hand covers the palmar surface of the metacarpal bones and
palmar interossei muscles.
Dorsal fasica of the hand (Fascia dorsalis manus) stretches on the back of the hand
between the sides of the first and fifth metacarpal bones. It covers the tendons of the extensor
muscles continuing upwards in their retinaculum.
 FIBROUS FORMATIONS OF THE FINGERS

These are represented by the mesotendons (Vincula tendinum). The tendons of the
flexor digitorum superficialis and profundus muscles are united between themselves, and
with the anterior surfaces of the phalanges, through thin bands which contain vessels, and
ensure the trophicity of the tendons without effecting their sliding movements. These bands
can be short (Vinculum breve), such as that between the terminal segment of the tendon and
the underlying planee, or long (Vinculum longum), such as that between the tendon and the
first phalanx.
Fibrous sheaths of the fingers (Vaginae fibrosae digitorum manus) are semi-cylindrical
formations placed on the anterior surface of the phalanges, with which they form an
osteofibrous sheath for the fixing of the flexor muscles’ tendons to the bone.They are formed
by two categories of fibers:
- Annular fibers (Pars anularis vaginae fibroasae) directed transversely towards
the body of the proximal and middle phalanges.
- Cross fibers (Pars cruciformis vaginae fibrosae) thinner, and situated near the
interphalangeal articulations.
Dorsal aponeurosis is a complex fibrous formation placed on the dorsal surface of the
fingers. Each tendon of the extensor digitorum muscle broadens, and isforming an
aponeurotic blade that adheres to the dorsal surface of each phalanx. The terminal tendons of
the interossei and lumbrical muscles also adhere on this expansion. As such, on the dorsal
surface of fingers II-V, the tendons are replaced by this fibrous fan that is attached to each
phalanx, and when the extensor contracts, this stretches the finger completely.

SYNOVIAL SHEATHS OF THE HAND AND FINGERS

Synovial sheaths of the flexor muscles:

- Synovial sheath of the flexor pollicis longus muscle (Vagina synovialis tendinis m.
flexoris pollicis longi) also called lateral digito-carpal sheath covers the tendon of the
homonymous muscle throughout all its length.
It is formed at 2-3 cm above the carpal tunnel and ends without being interrupted at the base
of the distal phalanx of the thumb.
- Flexor muscles’ synovial sheath (Vagina synovialis communis flexorum), or medial
digito-carpal sheath, covers the tendons of the flexor digitorum superficialis and profundus
muscles from the carpal tunnel up to the middle of the palm, where it ends the tendons of the
fingers II-III-IV, but it is continuing without interruption along the tendons of the fifth finger
up to the base of its distal phalanx.
- Synovial sheath of the fingers (Vagina synovialis tendinum digitorum). Synovial
sheath of the finger I and V communicates with the synovial sheaths of the palm and carpus
and is continuing them further. For fingers II, III, and IV, there is an individual sheath that
stretches from the metacarpophalangeal articulation up to the base of the distal phalanx.
These sheaths are isolated and do not communicate with the synovial sheaths of the palm and
carpus.
- Synovial sheaths of the extensor muscles. The tendons of the extensor muscles at the
level of the osteofibrous compartments from the wrist, in their passing underneath the
extensor retinaculum, are covered by synovial sheaths that have one or more tendons in each
compartment having, and are carrying the name of the muscles. These sheaths start above the
posterior annular ligament and end at the middle of the back of the hand.
Foto chist sinovial, mana, tenosinovita CLB
 BIOMECHANICS OF THE UPPER LIMB

The upper limb is connected to the trunk by only one joint, the sternoclavicular joint,
and by the extrinsic muscles of the back and thorax, with the terminal insertion on the
scapula. These muscles are:
• Vertebroscapular muscles:
• Trapezius muscle.
• Rhomboid major muscle.
• Rhomboid minor muscle.
• Levator scapulae muscle.
• Toracoscapular muscles:
• Serratus anterior muscle.
• Pectoralis minor muscle.

MOVEMENT OF THE SHOULDER

The fulcrum pointfor the movements of the pectoral arch is the clavicle, which the
scapula is suspended to through the acromioclavicular joint. The most important movements
are those of the scapula, which result in the amplification of the arm movements. The
scapular movements are achievable due to its muscular connection to the thoracic wall.
The junction of the interscapularthoracic muscular connection contains two sliding
spaces; one space is between the subscapularis muscle and serratus anterior muscle, and the
other is between serratus anterior muscle and the thorax; the latter being very important for
the movements of the shoulder blade.
The mobilizing muscles of the pectoral arch are part of the thorax and back muscles,
which have their terminal insertion on the scapula, clavicle, and the superior extremity of the
humerus. These muscles act either on the shoulder, moving it in different directions, or only
on the shoulder blade, in its swinging movements. The functional classification of the most
important muscles is:
- Shoulder elevation:
- Trapezius muscle.
- Levator scapulae muscle.
- Shoulder depression:
- Trapezius muscle (lower fibers).
- Forward projection of the shoulder:
- Pectoralis minor muscle.
- Pectoralis major muscle (clavicular fibers).
- Serratus anterior muscle.
- Backward projection of the shoulder:
- Rhomboid major muscle.
- Rhomboid minor muscle.
- Latissimus dorsi muscle.
- Forward projection of the scapula:
- Serratus anterior muscle.
- Trapezius muscle (superior part).

ARM MOVEMENTS

In the glenohumeral joint, the joint with the highest degree of freedom, the movements
are executed by the motor muscles of the articulation, which are recruited from the shoulder
muscles, back muscles, and thorax muscles. These muscles maintain the contact of the
articular surfaces, and allow arm movements in all directions. They are grouped in:
- Flexors:
- Deltoid muscle (pars clavicularis).
- Coracobrachialis muscle.
- Biceps brachii muscle (caput breve).
- Extensors:
- Deltoid muscle (pars scapularis).
- Triceps brachii muscle (caput longum).
- Teres major muscle.
- Latissimus dorsi muscle.
- Abductors:
- M.supraspinatus.
- M.deltoideus.
- Adductors:
-Teres major muscle.
- Teres minor muscle.
-Infraspinatus muscle.
-Subscapularis muscle.
-Latissimus dorsi muscle.
-Pectoralis major muscle.
- Internal rotation:
-Teres major muscle.
-Subscapularis muscle.
-Latissimus dorsi muscle.
- External rotation:
-Infraspinatus muscle.
-Teres minor muscle.

We emphasize again that these muscles act only in the glenohumeral joint, and the
movements of the arm are amplified by the participation of the muscles of the pectoral arch,
namely:
- Lifting the arm to the vertical position:
- Serratus anterior muscle.
- Trapezius muscle, superior part.
- Rhomboid major and minor muscles.
- Levator scapulae muscle.
- Internal rotation:
- Latissimus dorsi muscle.
- Serratus anterior muscle.
- External rotation:
- Trapezius muscle.
- Rhomboid major and minor muscles.

FOREARM MOVEMENTS

The elbow has only one degree of freedom. The boney surfaces determine an exclusive
motion necessary to ensure the leverage of the forearm. The motor muscles of the elbow joint
are:
- Flexor muscles:
 - Brachialis muscle.
- Biceps brachii muscle.
- Brachioradialis muscle.
- The superficial muscles of the anterior group of the forearm (auxiliary in
function).
- Extensor muscles:
- Triceps brachii muscle.
- Anconeus muscle.
- The superficial muscles of the posterior group of the forearm. (Auxiliary function).
The forearm’s skeleton, besides the fact that it has the function of a fulcrum, intervenes
in the movements of pronation and supination of the hand through the radioulnar
articulations. The stable portion of these movements is the ulna, and the mobile one is the
radius, which due to the curvature of its shaft, along with rotationary movements,can make a
translational movement, and cross over the body of ulna. The movements of pronation and
supination are executed simultaneously and synergistically in the two radioulnar articulations
(proximal and distal). The motor muscles of these movements all have their terminal insertion
on radius.
The two muscular groups are:
- Pronator muscles:
- Pronator teres muscle.
- Pronator quadratus muscle.
- Brachioradialis muscle
- Supinator muscles:
- Supinator muscle.
- Biceps brachii muscle.
- Brachioradialis muscle.
The pronatory and supinatory movements of the hand may be accentuated through the
movements of internal and external rotation of the arm.

HAND MOVEMENTS

Radiocarpal and midcarpal articulations act together to place the hand in a good
position for prehension. The small articulation from the carpal region allowsthe ability of this
segment to adapt to mechanical stress, and gives it an increased resistance against trauma. We
emphasize the fact that while the ulna is the main connecting bone in the articulation of the
elbow, in the articulation of the hand with forearm, this role is accomplished by the radius,
which transposes the forces from the forearm to hand, and that during counterpressure (e.g.
falling with weight on the palm), the radius will suffer the shock and be fractured.
The motor muscles of the hand articulations are:
- Flexors:
- Flexor carpi radialis muscle.
- Flexor carpi ulnaris muscle.
- Palmaris longus muscle.
- Flexor digitorum superficialis muscle.
- Flexor digitorum profundus muscle.
- Flexor pollicis longus muscle.
- Extensors:
- Extensor carpi ulnaris muscle.
- Extensor carpi radialis longus muscle.
- Extensor carpi radialis brevis muscle.
 - Extensor digitorum muscle.
- Extensor pollicis longus muscle.
- Adductors:
- Extensor carpi ulnaris muscle.
- Flexor carpi ulnaris muscle.
- Abductors:
- Extensor carpi radialis longus muscle.
- Extensor carpi radialis brevis muscle.
-Flexor carpi radialis brevis muscle.
- Abductor pollicis longus muscle.
- Extensor pollicis longus muscle.
- Extensor pollicis brevis muscle.
The muscles of this articular complex have the role of putting the hand in different
positions, and fixating it to permit prehension. We mention that a certain degree of dorsal
extension of the hand allows a stronger grasp, due to the greater squeezing force in this
position of the long flexors of the fingers.
Prehension
The human hand is made of 29 bones, which are connected between them through a
large number of joints. Put in motion by a complicated musculotendinous system,they can
perform the action of prehension. The thumb plays a very important role in this movement.
The thumb is separated from the rest of the hand, and due to its elongated shape, trapezio-
metacarpal joint, and the high number of muscles inserted around it, can intervene in the act
of prehension through the movement of opposition. This is a movement characteristic to
humans.
To perform the act of prehension, the hand has two categories of muscles, namely: force
muscles with their origin on the forearm, and the intrinsic muscles of the hand.
The forced flexion movements of the fingers II-IV are executed by the flexor digitorum
superficialis and profundus muscles. These are multi-articular muscleswith simultaneous and
synergistic action. Their tendons, on the way to the fingers, pass through osteofibrous
tunnels, which are situated at the level of the carpal tunnel; the second pulley system is
formed by the osteofibrous tunnel of the proximal phalanx, and the third pulley system is
formed by the osteofibrous tunnel of the middle phalanx. The tendons, doubled in these
tunnels by synovial sheaths, slide 5-8 cm. Fibrous rings, besides those that maintain the
contact of the tendon with the skeleton of the pulleys, also have the role of transposing the
motor incitation of the muscular contraction on the fingers.
The forced extension movements of the fingers II-IV are executed by the extensor
digitorum muscle. This muscle has a less powerful contractile force than the flexor muscles,
so even the resting position, or physiological position of the fingers, is characterized through
a slight semi-flexion. The index finger may be stretched independently. This movement does
not influence the flexion of the other fingers, but the extension of one of the last fingers does
prevent the total flexion of the other two fingers.
The force muscles of the thumb are a part of the profound musculature of the forearm.
The flexor pollicis longus muscle strongly flexes the distal phalanx, and by continuing the
action, it flexes the thumb on hand. The thumb extensor muscles are inserted on the long
segment; on the first phalanx the extensor pollicis brevis muscle inserts, while the extensor
pollicis longus muscle inserts on the second phalanx. These muscles are capable of
performing the hyper-extension of the thumb, and serve the role of moving the thumb away
as much as possible from the rest of the fingers. The opening of the thumb is an important
action (along with the hand fixation) in prehension.
The precision muscles of the hand are represented by the three palmar muscular groups.
 The fingers II-V, execute fine movements due to the lumbrical, palmar interossei, and
dorsal interossei muscles. These muscles can extend the finger, while the
metacarpophalangeal articulation flexes the finger in the interphalangeal articulations, putting
it in a “long forceps” grasping position. The interossei muscles, along with this synergistic
function, have an antagonistic action of abduction and adduction of the fingers towards the
axis of the hand. As such, they increase and decrease the area that the hand can grasp.
The little finger has some independence in its movements due to the hypothenar
muscles. The most important movement is its increased abduction capability
The thumb, due to the thenar musculature, has a wide range of fine movements. The
most important of which is the movement of opposition.
The movement of prehension is made in two phases. It starts with the opening of the
hand, which necessary to grasp an object, and continues with its closure, which is necessary
to hold the object. The hand is capable, due to its mobile segments, to make different types of
prehension; namely:
Prehension with the whole hand. Fingers II-IV are flexed in the shape of a semicircle
around the object, which is fixed on the palm. The thumb is put in front of the other fingers,
and is grasping the object from the opposite side. In complete and strong flexion, the thumb is
put over the fingers II-IV, strengthening their action.
The palmar prehension. It is realized with two fingers; from which one is the thumb,
and the second one or two of the adjacent fingers. The grasp can be made with the thumb and
index finger, or the thumb,index, and middle finger. The arm of the resulting forceps may be
straight, with the fingers in extension at the level of interphalangeal articulations, or curved,
with the fingers in semi-flexion. The palmar prehension is a precise movement.
Of course, not only the hand participates in prehension, but also the entire upper limb
with its articular chain used to amplify the reach of the hand.
In addition to its main prehension function, the hand executes other actions, such as:
support, suspension, and pushing. It is also is an auxiliary mean of expressionwith its
multitude of gestures thatrepresent the secondary mimic system.
Introducere imagine cu miscarile membrului superior
 ARTERIES OF THE SUPERIOR LIMB

Arterial blood supply of the upper limb is provided by the axillary artery, its branches,
and a few arteries from subclavian artery as described in the throat.

AXILLARY ARTERY
(Arteria axillaris)

It lies in continuation of the subclavian artery. It appears from the the anterior edge of
clavicle, and continues to the free edge of the pectoralis major, where it becomes the brachial
artery.
The artery has an oblique trajectory (down and out), and is crossing the axilla. It is
covered here by the pectoral muscles, and their fasciae. It sits on first digitations of M.
dentatus anterior, attaches to the inner edge of the coracobrachialis muscle, and carries on
along it until it reaches the arm. It is accompanied in its entire length by the axillary vein,
which is placed medial to it, and also by the bundles of the brachial plexus. It has the
following collateral branches:
- Supreme thoracic artery (Arteria thoracica suprema): thin,arises from the upper
portionof the axillary artery, and continues on before being distributed to the pectoral
muscles.
- Thoracoacromial artery (Arteria thoracoacromialis): it branches off from the
anterior face of the artery, at the upper edge of the small pectoral muscle, and perforates the
clavipectoralis fascia. It is divided into:
- Acromial branch (Ramus acromialis): goes laterally, passes beneath the deltoid
muscle, and forms an arterial network on the acromion (Rete acromialis);
- Deltoid branch (Ramus deltoideus): located in the gap between the deltoid and
pectoralis major, and gives branches to them;
- Pectoral branches (Ramus pectorales): descend between the two muscles to
irrigate them.
- Lateral thoracic artery (Arteria thoracica lateralis): called the external mammary
artery; it arises from the axillary artery at the upper edge of the pectoralis minor. It descends
on the serratus anterior, and gives branches to the muscle and the mammary gland (Rami
mammari lateralis).
- Subscapular artery (Arteria subscapularis): it braches off from the axillary artery at
the bottom edge of the subscapular muscle, and returns in its course. After a short trajectory,
it is divided into:
- Dorsal thoracic artery (Arteria thoracodorsalis): continues in the trajectory of
scapular artery, descends on the free anterior edge of the great dorsal, and irrigates it together
with neighboring muscles.
- The scapular circumflex artery (Arteria circumflexa scapulae) goes back through the
omotricipital space, and attaches to the lateral edge of the scapula, descends on it, and
irrigates the muscles of the infraspinosus fossa.
- Anterior humeral circumflex artery (Arteria circumflexa humeri anterior): has
small diameter. Its origin is at the bottom of the axillary artery. It has a horizontal trajectory,
and surrounds from the front the surgical neck of the humerus, where it willbe covered by the
thoracobrachial and short head of the biceps. It distributes blood to the scapular humeral
joint.
- Posterior humeral circumflex artery (Arteria circumflexa humeri posterior ): it is
more voluminous, detaches from the back of the axillary artery at the same level as the
previous artery, and is often forming with it a common trunk of origin. It crosses the humero-
tricipital space, surrounds from posterior the surgical neck of the humerus,
humerus and distributes
blood to the deltoid and scapular-humeral
scapular joint. It anastomoses
nastomoses with neighboring arteries.

BRACHIAL ARTERY
(Artera brachialis)

The brachial artery is the continuation of the axillary artery from the lower edge of the
great pectoral muscle until the the fold of elbow, where it forks forks into its terminal branches,
namely the radial and ulnar artery. In the upper arm, the artery has a linear co course, while
below this, the course is slightly obliq
oblique.
ue. It is located superficially, and is accompanied by
two satellite veins, and the median nerve. In I Sulcus bicipitalis
talis medialis(described in regional
region
anatomy of the arm),, the brachial artery is placed on the medial intermuscular septum septum, and
then on the brachial muscle.
On the elbow it still lies superficial
superficially, and mediall to the brachial biceps tendon. That is,
between the tendon, and the round pronator muscle. It has the following collateral branches:
Deep brachial artery (Arteria profunda brachii): brachii) it is the most voluminous,
voluminous and
important branch. Itemerges
emerges from the lower edge of Teres major muscle,muscle heads towards the
back of the arm, and hovers between lateral and medial head of the triceps in the groove of
the radial nerve. Branches :
- Nutrient artery of the humerus ((Arteria nutriciae humeri).
- Muscular branches for muscles besides passing.
- Medial
ial collateral artery (Arteria
( collateralis media):it descends on the bback of arm
until the olecranon, where participates in the formation of the vascular network of the elbow
(Rete articulare cubiti).
- Radial collateral artery ((Arteria collateralis radialis): it descends on the lateral
intermuscular
scular septum of the arm to the vascular network of the elbow.
- Superior ulnar collateral artery (Arteria collateralis ulnaris superior):: it originates
on the middle arm, and perforates the medial intermuscular septum to descend behind it until
the medial epicondyle, where it ends in the vascular network of the elbow.
- Inferior ulnar collateral artery (Arteria collateralis ulnaris inferior):: it is
isfound in the
lower third of the arm, and has the same trajectory as the previous collateral artery
artery.

RADIAL ARTERY
(A. radialis)

The radial artery is the external

xternal branch of the brachial artery, and descends
descends, with two
satellite veins and superficial branch of the radial nerve, on the lateral side of the forearm
between brachioradialis and pronator teres muscles. It then continues on the tendon of flexor
carpi radialis.
In the wrist, it passes posteriorly beneath the carpal extensor tendons in the direction of
the first inter-metacarpal space, and perforates this space to reach the hand. Here, it arches
transversely toward the medial edge of the hand, and forms the deep palmar arch. It sends
branches along its entire trajectory:
- Radial recurrent artery (Arteria recurrens radialis): it detaches at the elbow, ascends
between brahioradial and brachial muscle to elbow network, and anastomoses with the radial
collateral artery.
- Palmar carpal branch (Ramus carpeus palmaris): originates to the inner edge of the
pronator teres to participate in the formation of the palmar carpal network (Rete carpi
palmaris).
- Superficial palmar branch (Ramus palmaris superficialis): arises from the radial
artery before bypassing the wrist. It crosses the thenar muscles, and anastomoses with the
terminal portion of the ulnar artery to form the superficial palmar arch.
- Dorsal carpal branch (Ramus carpeus dorsalis) goes across the dorsal face of carpus,
and participates in the formation of the dorsal carpal network (Rete carpi dorsalis), where
the following arteries begin:
- Dorsal metacarpal arteries (Arteriae metacarpeae dorsales) are placed along the
interosseous spaces III-IV. They divide into two branches, called the dorsal collateral arteries
(Arteriae digitales dorsales), which are distributed to the adjacent edges of the fingers.
- Dorsal artery of the thumb (Arteria princeps pollicis): it descends along the
metacarpal to the base of the proximal phalanx, where it divides into two digital arteries, one
for the thumb, and one destinated to lateral edge of the index (Arteria radialis indicis).
- Deep palmar arch (Arcus palmaris profundus) is formed by the terminal portion
of the radial artery, and the deep palmar branch of the ulnar artery. It is located beneath the
deep palmar fascia at the metacarpals base, and sends out the following branches:
- Palmar metacarpal arteries (Arteriae metacarpeae palmares): they are 3-4 in
number. They leave from the convexity of the arch, and descend in the interosseous spaces to
anastomoses with the common palmar digital arteries originating from the superficial palmar
arch.
- Perforating branches (Ramus perforantes): they are three in number. They
cross the interosseous muscles, and anastomose with the dorsal metacarpal arteries.

ULNAR ARTERY
(A.ulnaris)

It is internal branch of the brachial artery, and descends on the medial side of the
forearm. Its upper third has a downward and medially oriented oblique trajectory, and is then
continuing down to the outer edge of pisiform bone. The upper part of the artery has a deep
position, and is covered by the pronator teres muscle, the superficial flexor of fingers, and
flexor carpi radialis. Below this point, it is placed underneath the lateral margin of the flexor
carpi ulnaris, between the muscle and superficial flexor muscle of the fingers. At the level of
the wrist, it crosses the flexor retinaculum laterally from the pisiform, and continues in the
hand to form the superficial palmar arch. Along its path, it is accompanied by two satellite
veins, as well as the ulnar nerve. It has the following branches:
- Ulnar recurrent artery (Arteria recurrens ulnaris): it emerges above the pronator
teres, ascends medially, and after a short trajectory, divides into an anterior branch (Ramus
anterior) located between the round pronator muscle and brachial muscle, and a posterior
branch (Ramus posterior) that passes through the heads of the flexor carpi ulnaris on the
dorsal face of elbow. Both branches anastomose with the ulnar collateral arteries, and
participate in the formation of arterial network of the elbow.
- Common interosseous artery (Arteria interossea communis): it leaves off the back of
ulnar artery near its origin. After a short, profoundly-oriented, trajectory towards the top of
the interosseous membrane, it forks to form the:
- Anterior interosseous artery (Arteria interossea anterior), which is placed on the
front of the interosseous membrane, and is covered by deep flexors of the forearm. At the
superior edge of pronator teres, it crosses the interosseous membrane, goes posterior, and
ends in dorsal carpal vascular network. It irrigates deep muscles from the anterior face of the
forearm, and gives a branch (Arteria mediana) which accompanies the median nerve.
- Posterior interosseous artery (Arteria interossea posterior): it passes dorsally above
the upper edge of interosseous membrane. There, it descends beneath the posterior muscles of
the forearm, and ends in dorsal carpal vascular network.
Near its origin, the artery issues a recurrent interosseous artery (Arteria interossea
recurrens), which ascends in the direction of cubital vascular network.
- The dorsal carpal branch (Ramus carpeus dorsalis) starts over the pisiform bone, and
anastomoses with its homonymous artery that comes from the radial artery to form the dorsal
carpal vascular network.
- Palmar carpal branch (Ramus carpeus palmaris): it is a deep branch, which crosses
the front of the carpus, beneath the flexor tendons, to anastomose with its counterpart from
the radial artery, and to participate in forming the anterior carpal vascular network.
- Deep palmar branch (Ramus palmaris profundus) crosses hypothenar muscles,
bypassing in the lateral direction beneath them and anastomoses with the radial artery to form
the deep palmar arch.
- Superficial palmar arch (Arcus palmaris superficialis) is formed from the terminal
portion of the ulnar artery and superficial palmar branch of the radial artery. It is located
under the palmar aponeurosis, describes a curve at the middle of the palm. From the
convexity of arch are leaving the following arteries:
- Common palmar digital arteries (Arteriae digitales palmares communes ): there are
four in number for each of the last four fingers. They descend on the lumbrical muscles until
the level of interdigital commissures, where they are divided into two palmar digital arteries
(Arteriae digitales palmares propriae) destinated for the adjacent edges of fingers II-V.
They irrigate the palmar and dorsal sides of the last phalanx, including the nail matrix.
Arteriografie membru superior sau CT
Eco Doppler axilar, brachial, axilar
 THE VEINS OF THE SUPERIOR LIMB

The upper limb, has two venous systems: one deep (located subfascially), which
accompanies the corresponding arteries with two veins for each artery. There is a notable
exceptions ofthe axillary vein, and other superficial veins that are located in the subcutis.
Between the two systems, there are numerous venous anastomoses.

DEEP VEINS

- Superficial palmar venous arch (Arcus venosus palmaris superficialis) corresponds

to the homonymous arterial arch; it collects palmar digital veins (Venae digitales palmares),
and continues in the the deep veins of the forearm.
- Deep palmar venous arch (Arcus venosus palmaris profundus) that accompanies the
deep arterial arch, and collects palmar metacarpal veins (Venae metacarpeae palmares). It
continues as the deep veins of the forearm.
- Venele radiale (Venae radiales) accompany the radial artery, but are smaller than the
artery.
- Ulnar veins (Venae ulnares) are satellite veins of the ulnar artery, and are also with a
smaller diameter.
- Brachial veins (Venae brachiales) accompany the brachial artery to the lower edge of
subscapular muscle to merge in the axillary vein. They gather veins corresponding to the
terminal and collateral branches of the brachial artery.
- Axillary vein (Vena axillaris) is formed from the union of the two brachial veins, and
vena basilica. It has a larger diameter, and lies medial to axillary artery. It partially covers the
artery. It collects the following veins:
- Tributaries corresponding to the branches of axillary artery, superficial veins of the
chest wall (thoraco-epigastric veins), and the cephalic vein (Vena cephalica).

SUPERFICIAL VEINS

- The dorsal venous network of the hand (Rete venosum dorsale manus) collects the
veins of the fingers that unite in the dorsal metacarpal veins (Venae metacarpales dorsales).
- The network collects a part of the blood from the palmar face of the fingers through
thin veins that cross the interosseous space between the ends of the metacarpals (Venae
intercapitales).
- The network continues laterally with the cephalic vein, and medially with the basilic
vein.
- Cephalic vein (Venae cephalica) climbs the lateral edge of the forearm, elbow, and
arm. It reaches the gap between the deltoid and pectoralis major muscle, perforates the
superficial fascia, and is situated inside a reflection of the fascia. Near the clavicle, it goes
deeper to crossthe doubling of the superficial fascia, and fascia clavipectoralis. It ends by
flowing into the axillary vein. Before its termination, it collects the thoracoacromial veins.
- In some cases, on the back of forearm, there is a thick vein (Vena cephalica accesoria).
- Vena basilica (Vena basilica) ascends on the medial edge of the forearm, passes anteriorly
on the elbow, and continues in the subcutis of the arm along the medial edge of the biceps. It
perforates the brachial fascia at the middle of the arm, and joins with the brachial veins to
form the axillary vein.
- Median vein of the elbow (Vena mediana cubiti): it is relatively thick anastomotic branch
between aforementioned veins. It has an oblique trajectory, upwards and medially from the
cephalic vein to basilic vein. It communicates through a perforated branch with the deep
veins of the elbow.
- Median vein of the forearm (Vena mediana antebrachii) is found on the midline of the
anterior face of forearm. It can be tributary to either the cephalic vein, the basilic vein, or
both. In the latter case, it will divide on the elbow into a "Y"-shape. The lateral branch is
called the mediocefalic vein (Vena mediana cephalica), and the other medial branch is
called the mediobasilic vein (Vena mediana basilica). This usually anastomoses with the
deep veins of the elbow.
Eco Doppler
Imaginer cu port citostatic
 THE UPPER LIMB LYMPHATICS

The upper limb has superficial andprofound lymphatic networks, which are both
composed of vessels and lymph nodes. The two lymphatic networks are collected by the
axillary lymph nodes, from which emerges a corresponding trunk, namely the subclavian
trunk (Truncus subclavius). This trunk empties in the thoracic duct on left side, and into the
right lymphatic duct on the right side.

THE SUPERFICIAL NETWORK

It is also called the suprafascial network, and it collects the lymph of superficial upper
lim. The network consists of the lymphatic plexus of the fingers, and the lymphatic network
of the dorsal hand. The lymph of the palm is also drained to the dorsal hand, where three
collector ways detach to accompany the superficial veins of the upper limb on the front of the
forearm and the arm. Thus, we distinguish the medial lymphatic vessels alongside the basilic
vein, the lateral corresponding to the cephalic vein, and the median lymphatic pathways
associated with the median vein of the forearm.
On their pathway, we find the following lymph nodes:
- 2-3 cubital lymph nodes (Nodi lymphatici cubitales) located above the medial
epicondyle. They filter the lymph of the medial half of the hand and forearm. Their efferents
progress along the basilic vein drain into the axillary lymph nodes.
- the deltoidopectoral lymph nodes are placed on the path of the cephalic vein into
the deltoidopectoral groove. They filter the lymph of the lateral half of the forearm and arm,
and their efferents head towards the axillary lymph nodes.

THE DEEP NETWORK

Also called subfascial network, this network collects the lymph from the muscles,
joints, periosteum, and bones. The network is arranged along the deep blood vessels.
The network starts in the palms, accompanying the radial veins, the ulnar interosseous
veins, and the brachial veins, to the axillary lymph nodes.
The 20-30 axillary lymph nodes (Nodi lymphatici axillares) are placed into the
adipose tissue surrounding the axillary vessels. They collect the lymph of the entire upper
limb, and are irrigated both by the superficial network and the deep one. It is divided into the
following 5 groups;
The lateral or brachial lymphocenters (Nodi lymphatici laterales); they areplaced
posterolaterally to the axillary vein, and drain the upper limb lymph.
The pectoris lymphocenters (Nodi lymphatici pectorales); they are placed along the
lateral thoracic vessels, and collect the lymph of the above umbilical cord area, including that
of the central and lateral breast area.
The subscapularis lymphocenters (Nodi lymphatici subscapulares) are arranged on the
path of the scapular vessels, and they drain the lymph of the neck and back.
The central or the intermediate group (Nodi lymphatici centrales); they located in the
middle axilla, and collect the lymph from the first three groups.
The apical or the subclavicular group (Nodi lymphatici apicales); they are located on
top of the axilla (drains the lymph of all the preceding groups, and the deltoidopectoral
lymph). Their efferents form a collecting channel, the subclavian trunk (Truncus subclavius
), which flows into the large collecting lymphatic vessels.
 THE UPPER LIMB NERVES

THE BRACHIAL PLEXUS

(Plexus brachialis)

The plexus formed by anastomosis of the anterior branches of the last four cervical
nerves (V, VI, VII and VIII), and the first thoracic nerve, which together form the root of the
brachial plexus.
The plexus crosses the infero-lateral part of the neck, and enters the axilla, where it
divides into its terminal branches for the upper limb.
We will come back upon the more detailed topographic relations in our discussion of
the lateral cervical and axillary region.
There are different aspects in the neck versus the axilla, and thus, we are able to
distinguish a supraclavicular and an infraclavicular area:
- The supraclavicular area (Pars supraclavicularis); is constituted from three primary
trunks (Trunci plexus), which form in the space between the anterior and the middle scalene
muscle (scalene hiatus), as follows:
- The superior trunk (Truncus superior); it results from the merging of the cervical
nerves V and VI.
- The middle trunk (Truncus medius); it is composed of the VII-th cervical nerve.
- The inferior trunk (Truncus inferior) is made of the joining of the VIII-th cervical
nerve and I-st thoracic nerve.
After a short distance, each primary trunk divides into an anterior (anterior secondary
trunk) and posterior part (posterior secondary trunk).
From the trunks of the supracavicular area, emerge the motor nerves destined for the
muscles of the arm, and the extrinsicmuscles of the back and thorax. We also mention that
sometimes, some of these branches are attributed to the infracavicular area:
- Nervus dorsalis scapulae.
- Nervus thoracicus longus.
- Nervus subclavius.
- Nervus suprascapularis.
- Nervi pectorales.
- Nervus subscapularis.
- Nervus thoracodorsalis.
- The infracavicular area (Pars infraclavicularis) is composed of three fascicles
disposed around the axillary artery, and are named in relation with their positioning around
the artery. The fascicles form the secondary trunks of the supracavicular area as follows:
- The lateral fascicle (Fasciculus lateralis) forms from the front part of the superior,
and middle trunk.
- The median fascicle (Fasciculus medialis) continues the front part of the inferior
trunk.
- The posterior fascicle (Fasciculus posterior) ismade up from the merging of the
posterior divisions of the secondary trunks, which arose from the three primary trunks.
The motor and sensitive terminal branches detach from the fascicles of the brachial
plexus, and are intended for the free upper limb, which indicate the neuromas(Tumors?), and
the most important are:
- From the lateral fascicle:
- Nervus musculocutaneus (C5-7).
- Nervus medianus, radix lateralis (C5,8).
- From the median fascicle:
 - Nervus medianus, radix medialis (C8, Th1).
- Nervus ulnaris (C8, Th1).
- Nervus cutaneus brachii medialis..
- Nervus cutaneus antebrachii medialis.
- From the posterior fascicle :
- Nervus axillaris (C5,6).
- Nervus radialis (C5-7, Th1).

THE SUPRACAVICULAR BRANCHES

The dorsal scapular nerve (Nervus dorsalis scapulae), arises near the roots of the upper
trunk, crosses the middle scalene muscle, descends on the deep front of the levator muscle of
the scapula, and gives branches to it and rhomboids.
The long thoracic nerve (Nervus thoracicus longus), also called „Bell’s respiratory
nerve”, forms in the root of the plexus; it crosses the median scalene, bypasses from behind
the axillary vessels, and continues on the lateral surface of the great splenius muscle, which
it innervates.
The subclavicular nerve (Nervus subclavius) arises from the superior trunk; it descends
prior to the subclavicular artery to the subclavian muscle.
The suprascapular nerve (Nervus supracapularis) starts from the superior trunk, heads
laterally along the inferior part of the omohyoid muscle. It then passes through the scapular
notch, beneath the transverse ligament in the supraspinatus fossa depth, then descends down
on the side of the scapula into the infraspinatus fossa to innervate the muscles located here.
The pectoral nerves (Nervus pectoralis lateralis et medialis) are destined for the
pectoral muscles; they head downwards, and pass, prior to the axillary artery, to the
aforementioned muscles.
The subscapular nerve (Nervus subscapularis) descends on the posterior wall of the
axilla to the subscapular and the great round muscles.
The thoracodorsal nerve (Nervus thoracodorsalis) starts from the posterior part of the
brachial plexus trunks, descends on the posterior wall of the axilla, and it distributes fibers to
the large dorsal muscles.
 THE INFRACAVICULAR BRANCHES

THE MUSCULOCUTANEOUS NERVE

(Nervus musculocutaneus)

Laterally located to the axillary artery, this nerve forms from the lateral fascicle, crosses
the coracobrachialis muscle obliquely in it’s middle part, and then places itself in the
interstitial space between the biceps and the brachialis muscle. It then descends towards the
elbow, and continues through its terminal branch on the forearm. It issues :
- Muscular branches (Rami musculares) for the anterior muscles of the arm.
- Lateral cutaneous nerve of the forearm (Nervus cutaneus antebrachii lateralis); it
crosses the arm’s fascia near the elbow, attaches to the cephalic vein, and innervates the skin
on the lateral edge of the forearm.

THE MEDIAN NERVE

(Nervus medianus)

It arises from two roots; the lateral one (Radix lateralis) comes from the lateral
fascicle, and the medial one (Radix medialis) from the medial fascicle. These merge into a
sharp angle in front of the axillary artery. The nerve crosses the axilla, the arm, and forearm,
to divide in its terminal branches in the palm.
In the axilla, it is placed on the front side of the axillar artery. On the arm, in its upper
part, it is laterally located to the branchial artery. Then it crosses over the artery in the inferior
part of the arm, and passes it medially. It reaches the forearm between the two heads of origin
of the round pronator muscle, and is located between the superficial and deep flexor muscles
of the fingers in the median axis of the forearm, from where its name comes from. In the
inferior part of the forearm, it becomes more superficial, and is located between the flexor
carpi radialis muscle and long palmar muscle. It crosses the wrist through the carpal channel
to reach the palm, where it distributes beneath the palmar aponeurosis in its terminal
branches. It issues branches only from the elbow downwards, as follows:
- The muscular branches (Rami musculares); they detach in the elbow’s articulation
and innervate all the anterior muscles of the superficial forearm, with the exception of the
ulnar flexor carpi.
- The anterior interosseous nerve (Nervus interosseus anterior) accompanies the
homonymous artery; it descends on the interosseous membrane, between the deep flexor of
the fingers and the long flexor of the thumb, and innervates them together with the square
pronator muscle.
- The palmar branch (Nervus palmaris mediani) perforates the forearm’s fascia above
the carpus, and distributes itself to the palm’s skin and to the thenar eminence.
- The muscular palmar branch detaches from the median nerve in the carpal channel,
crosses the flexor retinaculum, and penetrates into the thenar musculature. It innervates all
the thenar musculature, with the exception of the thumb’s adductor.
- The three common digital palmar nerves (Nervi digitales palmares communes) are
terminal branches of the median nerve. They are located beneath the palmar aponeurosis,
together with their homonymous arteries. They head towards the fingers in order to divide
into their own palmar digital nerves as follows:
- The first common palmar nerve divides itself into branches intended for the two sides
of the thumbs, and lateral edge of the index. It also gives a motor branch for the first
lumbrical muscle.
 - The second common palmar digital nerve innervates the second lumbrical, and gives
two branches for the adjacent sides of the index and medius fingers.
- The third common palmar digital nerve distributes towards the neighbouring sides of
the medius and annular fingers.
- The palmar digital nerves proper(Nervi digitales palmares proprii); they are
sensitive nerves, which innervate the palmar surface of the first seven fingermargins. In the
terminal phalanx of these fingers, they pass posteriorly, and innervate the skin at this level.
- The communicating branch with the ulnar nerve (Ramus communicans cum nervo
ulnari) detaches from the third common digital palmar nerve.

THE ULNAR NERVE

(Nervus ulnaris)

It forms from the medial fascicle in the axilla; it descends together with the brachial
artery on the medial surface of the arm, crosses the brachial medial intermuscular septum,
and continues forward towards the posterior. On the elbow, it bypasses the medial
epicondyle, to place itself in the groove of the ulnar nerve. It then reflects forward, and passes
through the two heads of origin of the ulnar carpi flexor on the medial side of the forearm.
Here, it descends vertically on medial side of the ulnar artery, crosses the retinaculum of the
flexors lateral to the pisiform bone, and divides in its terminal branches. Starting from the
elbow, it issues the following branches:
- The muscular branches (Rami musculares) arise in the elbow, and innervate the ulnar
carpi flexor and the inside half of the deep flexor of the fingers.
- The cutaneous palmar branch (Nervus cutaneus palmaris) is destined for the
hypothenar tegument.
- The ulnar’s nerve dorsal branch (Ramus dorsalis ulnaris), or the dorsal branch of the
hand, is the sensitive branch that arises in the inferior half of the forearm. It passes dorsally
between the ulnar carpi flexor and the ulna, and it distributes itself to the skin of the posterior
side of the hand(in its medial half) and to the fingers:
- The dorsal digital nerves (Nervi digitales dorsales) descend towards the last
interosseous spaces, and divide in branches for the last five margins of the fingers to
innervate the skin on the posterior face of the first two phalanges.
- The palmar branch of the ulnar nerve (Ramus palmaris nevus ulnaris). It is the
terminal branch, which divides into a superficial sensitive branch and a profound motor one:
- The superficial branch (Ramus superficialis) descends in the hypothenar to
innervate its skin.It then divides in the common digital palmar nerves (Nervi digitales
palmares communes) and proper nerves (Nervi digitales palmares proprii), which are for
the innervation of the palmar face of the last three fingers edges. It also innervates the skin on
the dorsal face of the terminal phalanx, which corresponds to the edges of the aforementioned
fingers.
- The profound branch (Ramus profunda) penetrates together with the same branch
of the ulnar artery, between the abductor and the flexor of the small finger. It is directed
laterally, and places itself transversely beneath the deep palmar fascia to accompany the deep
palmar arch. It is the most important motor branch of the hand, and by its branches (Rami
musculares), it innervates most of the palm’s muscles (14 muscles of the 19 total palmar
muscles).
 THE MEDIAL CUTANEOUS NERVE OF THE ARM
(Nervus cutaneus brachii medialis)

It is a thin nerve, which comes from the medial fascicle of the brachial plexus. It
descends medial to the axillary artery, then medial to the brachial one, and after a short
trajectory, it penetrates the fascia to distribute itself to the skin of the internal side of the arm.

THE MEDIAL CUTANEOUS NERVE OF THE FOREARM

(Nervus cutaneus antebrachii medialis)

It descends together with the aforementioned nerve to the middle of the arm. It
perforates the brachial fascia together with the basilic vein, and is found superficially. On the
anterior side of the elbow it divides into two branches:
- The anterior branch (Ramus anterior); this goes along the basilic vein, and it
distributes to the skin on the anteromedial face of the forearm.
- The ulnar branch (Ramus ulnaris) innervates the skin on the postero-medial side
of the forearm.

THE AXILLAR NERVE

(Nervus axillaris)

It comes from the posterior fascicle of the brachial plexus. Located in the rear of the
axillary vein, on the subscapularis muscle, it directs itself downwards and outwards. It
crosses the humerotricipital space, posteriorly bypasses the surgical neck of the humerus,
beneath the deltoid, and distributes into:
- Numerous muscular branches (Rami musculares), which detach from the terminal
part of the nerve on the profound face of the deltoid.
- Superior lateral brachial cutaneous nerve (Nervus cutaneus brachii lateralis
superior); it perforates the fascia on the posterior edge of the deltoid, and innervates the skin
on the superlateral surface of the arm.

THE RADIAL NERVE

(Nervus radialis)

It continues the posterior fascicle of the brachial plexus; it crosses the axilla in the rear
of the axillary artery, located on the subscapular muscle. On the arm, it orientates itself
obliquely (downwards and outwards) on the dorsal face of the humerus into a groove that
carries its name. It is then crossing the space between the long and the medial head of the
triceps. In this groove, it has a spiral trajectory covered by the brachial triceps, and
accompanied by the deep artery of the arm. Then, it perforates the lateral intermuscular
septum, passes anterior to it, between the brachial muscle and the brachioradial muscle, and it
divides above the head of the radius into superficial and profound terminal branches. The
collateral and the terminal branches of the nerve are:
- The muscular branches (Rami musculares); they detach in the axilla and on the arm.
They innervate the triceps, the anconeus, the brachioradial, and the long radial extensor of the
carpus.
- The posterior cutaneous nerve of the arm (Nervus cutaneus brachii posterior)
detaches in the axilla, and innervates the skin of the dorsal part of the arm.
- The inferior lateral cutaneous nerve of the arm (Nervus cutaneus brachii lateralis
inferior) innervates the skin on the posterolateral face of the inferior part of the arm.
 - The posterior cutaneous nerve of the forearm. (Nervus cutaneus antebrachii
posterior) crosses the fascia in the inferior third of the dorsal arm, and continues on the
forearm, where it innervates the skin of its posterior side.
- The superficial branch (Ramus superficialis) is the sensitive terminal branch of the
radial nerve. It descends vertically, covered by the internal edge of the brachioradial, and is
found lateral to the radial artery. In the inferior third of the forearm, it continues posteriorly,
and passes beneath the brachioradial muscle to the dorsal part of the carpus and hand. It
emits:
- Sensitive branches for the lateral half of the skin from the dorsal side of the hand.
- Dorsal digital nerves (Nervi digitales dorsales) for the first 5 finger margins.
They innervate the skin on the face of the first two phalanges in the aforementioned area.
- The profound branch (Ramus profundus) is the terminal motor branch of the
nerve. It passes through the supinator muscle, and locates itself between the superficial and
deep group of the forearm extensors. It becomes more and more profound, continues on the
interosseous membrane, and is hereby called the posterior interosseous nerve (Nervus
interosseus antebrachii dorsalis)up to the radiocarpian joint. It issues muscular branches for
all posterior muscles of the forearm.
 Eco nerv median, .....
Desen cu inervatia cutanata
 THE TOPOGRAPHIC REGIONS OF THE UPPER LIMB

Anatomo-topografically speaking, the upper limb divides in the following regions (Regiones
membri superioris).
- The regions of he shoulder:
- The axillary region (Regio axillaris).
- The scapular region (Regio scapularis).
- The deltoid region (Regio deltoidea).

- The regions of the arm:

- The anterior brachial region (Regio brachii / brachialis anterior).
- The posterior brachial region (Regio brachii / brachialis posterior).

- The regions of the elbow:

- The front region of the elbow (Regio cubit / cubitalisi anterior).
- The posterior region of the elbow (Regio cubiti / cubitalis posterior).

- The regions of the forearm:

- The front antebrachial region (Regio antebrachii anterior).
- The posterior antebrachail region (Regio antebrachii posterior).

- The regions of the wrist:

- The front carpal region (Regio carpi / carpalis anterior).
- The posterior carpal region (Regio carpi / carpalis posterior).

- The regions of the hand:

-The palmar region or the palm of the hand (Palma manus).
- The dorsal region or the back of the hand (Dorsum manus).
- The front region of the fingers of the hand.
- The posterior region of the fingers of the hand.
The regions of the upper limb are stratigraphically constituted of various overlapping
planees, with each in turn being made of distinctive layers that contain the formations of the
region. The main planees are:
The covering plane,or the superficial planee, is made of three overlapping planees as
follows:
- The skin is generally thin, mobile, and hairless in the front regions, and more
thickened and hairy in the posterior regions. In the joint regions, the skin forms various folds
that mark the flexion creases which generally correspond to the interarticular lines.
- The subcutis has a variable thickness, and a lamellar, or areolar, structure
It contains the vascular and nervous formations of the region as follows: the superficial
arteries are thin branches, and generally without importance. They get here from the deeper
planees by perforating the superficial fascia.
- The superficial voluminous veins are variable and represent the access for venous
puncture.
- The lymphatics of the subcutis belong to the superficial network, and drain
themselves by some superficial lymph nodes, or directly in the axillary lymph nodes.
- The superficial nerves are cutaneus nerves, and come from the terminal branches of
the brachial plexus. They insure the segmentary innervation of the skin of the upper limb as
follows:
- C4: the shoulder (from the cervical plexus)
 - C5: the arm, the lateral part
- C6: the forearm, the lateral part
- C7: the hand, the lateral third
- C8: the hand, III-IV fingers
- Th1: the hand, the forearm, the arm, the medial part
- Th2: the arm, the medial part
- The superficial fascia is a resistant fiber conjunctive formation, and has certain
particularities from one region to another. It sends deep intermuscular septa that contribute to
the delimitation of the muscular spaces.
The subfascial planecontains the muscles, the tendons, and the profound vascular-
nervous formations of the region.
- The muscles located in osteofibrous spaces form more overlapping layers, and are
separated amongst themselves by intermuscular spaces, or interstitial spaces, which allow for
their sliding movements. At the same time, they represent contention spaces of the vascular
and nervous elements. Generally the tendons are located in fibrous tunnels, and are coupled
with synovial sheaths.
- The profound vessels and the nerves of the regions are generally grouped in bundles,
or neurovascular pedicles, located in the intermuscular interstitial spaces along side some
muscles, which represent their satellite muscles. The projection and discovery of the main
arterial and venous trunks will be described in each region in a separate subchapter.
- The osteo-articular planee of the region is composed of the backbone; respectively, it
is the joint that enters into the constitution of the region. We will briefly refer to this planee,
as the necessary notions can be encountered in osteology and arthrology chapters.
MEMENTO: Within the topographic regions, the systematic anatomical details and
the technical terms are not repeated. Thier knowledge is only supposed.
 THE REGIONS OF THE SHOULDER

The shoulder, or the root of the upper limb, is constituted of a set of formations
disposed around the scapular belt and the scapulohumeral joint. From anatomo-topographical,
practical, and surgical considerations, it divides in three regions: the axillary, the scapular,
and the deltoid region. Of these, the axillary region represents the passage territory of the
vascular and nervous formations towards the upper limb.

THE AXILLARY REGION

(Regio axillaris)

Having the shape of a quadrangular pyramid, it is made of anatomical elements that

realize the junction between the trunk and the arm; interspersed between the scapular-
humeral articulation, the thoracic wall, and the front part of the scapula. Topographically, we
distinguish walls and content. The four walls of the pyramid, together with the base and the
peak, delineate a large space, called the gap or the axillary niche (Spatium axillare), where
lie the vascular-nervous formations of the region.
Limits: the region has limits on the skin only corresponding to the front wall and the
base, as follows:
- The front: clavicle, the free margin of the large pectoral, the deltoidpectoral groove
and a conventional line that unites the middle of the clavicle with the inferior end of the free
margin of the great pectoral (where it detaches of the thoracic wall).
- The base: having a quadrilateral shape, it is delineated by the front and the posterior
axillary fold, and by two horizontal lines; the superior one unites the insertion points on the
arm of the great pectoral and of the great dorsal; the inferior one is seated on the lateral wall
of the thorax where these muscles detach of the thoracic wall.
In depth, the region extends to the shoulder’s joint, the front-lateral wall of the thorax,
and the front face of the scapula.
The exterior shape:the region is studied with the arm in three different positions,
namely:
- The clinical position is with the arm in abduction, and allows the exploration of
the axillary contents, due to the relaxation of the covering plane.
- The anatomical position is with the arm in abduction up to the horizontal line, and
is used for the disection of the region. In this position the contents of the axilla are placed on
the longitudinal axis of the pyramid.
- The surgical position is with the arm in forced abduction, where the contents of the
axilla become more superficial, nearby the vicinity of the basal region.
On inspection, inferior to the clavicle, one canremark a basin, called the Mohrenheim
infracavicular fossa, which corresponds to the deltoidopectoral space. This territory, in some
literature and in international terminology,corresponds to the infracavicular region (Regio
infraclavicularis). We consider this part of the front wall of the axillary region, and as a
result, it is not justified to include it in a separate description.
The basis is hollowed, and covered with hair. This indentation is called the axillary
fossa (Fossa axillaris); this is a term which refers at a surface detail, and not to the big space
between the walls, which as it has been shown is called niche or hole.
At the basis of the axilla, one can find the axillary folds. The front axillary fold (Plica
axillaris anterior)is at the free margin of the greater pectoral muscle, and the posterior
axillary fold (Plica axillaris posterior) is determined by the free margin of the great dorsal.
In its depth, one can palpate the shape of the anterior muscles: the coracobrachialis, and
the short head of the biceps; the pulsations of the axillary artery and eventually the lymph
nodes. On the bottom of the axillary fossa one can perceive the head of the humerus, and its
movements.
The walls of the axillary region:
The anterior wallis formed of a covering planee and two musculo-fascial planees.
- The covering plane is composed of the mobile skin. The underskin tissue is of variable
thickness. The external parietal fascia is dependent on the superficial fascia (extracorporal) of
the trunk. The subcutis contains a venous network (the prepectoral network), and the
cutaneous nerves, which are branches of the cervical plexus (the supracavicular nerves).
- The superficial musculo-fascial planee is composed of the great pectoral muscle, and
the pectoral fascia (Fascia pectoralis) that dresses the front part of the pectoral, and also
sends a profound thin blade on the posterior surface of the muscle.
- Between the deltoid muscle and the supero-external margin of the great pectoral, one
can find another depression called the deltoid-pectoral groove (Sulcus deltoideopectoralis),
which enlarges towards the clavicle to form the deltoid-pectoral triangle. This depression is
superficially covered by the pectoral fascia, and contains the following elements:
-the cephalic vein is located in doubling of the fascia, forms a putter, and flows in
the axillary vein. At this level, the cephalic vein usually has few affluents, namely the
thoracic acromial veins which are relatively constant.
- the thoracic-acromial artery is located in the depth of the groove, and distributes
to its branches at this level.
- 1-2 deltoid-pectoral lymph nodes are located on the path of the cephalic vein.
- The deep musculo-fascial plane is composed of the subclavian muscle and the small
pectoral, namely the clavipectoral fascia (Fascia clavipectoralis). The small pectoral
delineates together with the clavicle an empty muscular space, called the „clavipectoral
triangle”, where the contents of the axilla have a slightly superficial position.
- The clavipectoral fascia starts on the inferior face of the clavicle, forms an
osteofibrous sheath for the subclavian muscle, passes over the clavipectoral triangle, and
reaches the superior margin of the small pectoral. In this location, it duplicates in two foils
that cover the front and the posterior face of the muscle, comprising it into a sheath. The two
foils merge on the inferior margin of the small pectoral, and continue towards the basis of the
axilla with the axillary fascia.
In the clavipectoral triangle, the fascia is perforated by the cephalic vein, the
acromioclavicular artery, and the vascular and venous formations intended for the great
pectoral.

Between the two musculo-fascial planes, there is the interpectoral interstitial space,
which is a slidingplanee for the pectoral muscles. It contains lamellar celluloadipose tissue
where the following formations descend towards the pectoral muscles:
- the supreme thoracic artery and the accompanying veins.
 - the pectoral branches of the thoracoacromial artery and the satellite veins.
- the lateral and medial pectoral nerves
- lymph nodes
The posterior wall is located deeply, and is formed of the external part of the
subscapular muscles, the great round, and the big dorsal.
The posterior wall of the axilla communicates through the humerotricipital space with
the scapular region, and through the omotricipital space with the deltoid region. These two
spaces are described in more detail in the scapular region.
The following vascular and nervous formations are attached to the posterior wall:
- the circumflex artery of the scapula, with two accompanying veins, that heads
towards the omotricipital space.
- the thoracodorsal artery, with its satellite veins, descends on the free front margin
of the big dorsal.
- the subscapular nerve, which is located near the lateral margin of the muscle with
the same name.
- the thoracodorsal nerve descends along the front margin of the big dorsal together
with its homonymous vessels.
- the subscapular lymph nodes are strung on the path of the subscapular vessels.
The medial wallis composed of the superior-lateral part of the thoracic wall, and is
covered by the first formations of the big dented muscle.
On this wall, beneath a thin cellular blade, is found:
-the lateral thoracic artery, which descends together with its satellite veins onto the
lateral side of the anterior serrated muscle.
- the long thoracic nerve descends parallely with the precedent vessels, and has the
same trajectory.
-the 1-2 intercostal brachial nerves (Nervi intercostobrachiales) are perforating the
branches from the II-III intercostal nerves. They cross the formations of the anterior serrated
muscle, and head towards the medial side of the arm.
- the 5-6 pectoral lympocentersi are found along the lateral thoracic vessels
The lateral wall is composed of the tendons of the coracobrachial muscle and the short
head of the biceps, and is covered by the brachial fascia.
The basis of the axilla or the inferior wall is composed only from the covering plane:
- the skin is covered by hairs, thin, retracted, and adherent to the underlying fascia;
it contains various sebaceous glands.
- the subcutis has a compartmental structure, and it contains vessels, nervous
branches and many sweat glands.
- the axillary fascia (Fascia axillaris),or the “suspensory ligament of the axilla of
Gérdy”, is composed of the pectoral and clavipectoral fascial fussion. It heads backwards and
continues in the fascia of the big dorsal.
The tip of the axilla is a osteofibrous orifice thatcommunicates with the lateral region of
the neck (the supracavicular region). Through it, pass the vascular-nervous axillary bundle. It
is delineated by the clavicle and the subclavian muscle in the front; lateraly and at its back, by
the coracoid apophysis and the coracoclavicular ligament; medially, by the joining of the
clavicle with the first rib.
The content of the axillary pit:
The axillary pit is filled with rich conjunctive-fat tissue where are placed the vascular,
the lymphatic and the nervous formations of the axilla.
The axillary artery crosses the axillary pit, and is located in its axis. Its trajectory is
influenced by the position of the arm, namely: in anatomical position the artery is rectilinear;
it curves in surgical position, which describes convexity towards the basis of the axilla; in
clinical position, it forms a curvature with a downwards headed concavity. In relation to the
small pectoral muscle, three parts of the axillary artery are distinguished, namely:
- Part I, or the clavipectoral part, is located in the clavipectoral triangle, between
the clavicle and the superior margin of the small pectoral.
- Part II, or the retropectoral part, is placed beneath the small pectoral.
- Part III, or the postpectoral part, is found between the inferior margin of the
small pectoral and the free margin of the big pectoral.
Reports:
- The first part is covered by the superficial musculofascial planee, and by the
clavipectoral fascia of the front wall of the axilla. Backwards, it lays on the first formations of
the anterior serrated muscle and the underlying ribs.The axillary vein is found medially, and
it usually covers part of the artery and the lateral brachial plexus, which in this part, regroups
in fascicles.
- The second part is located more profoundly beneath the three planees of the frontal
wall. Posteriorly, it comes in torelationship with the subscapular muscle. The axillary vein is
placed medially to the artery. The fascicles of the brachial plexus group laterally, medially,
and posteriorly around the artery.
- The third part, after coming in to contact posteriorly with the big round muscle and the
big dorsal, it attaches to the medial face of the coracobrachial, along with whom it passes into
the region of the arm. At this level, the terminal branches of the brachial plexus arrange
around the artery.
Branches:they are collaterals of the axillary artery, and have the following emergences:
- The front branches detach from the first part. These are: the supreme, the
thoracoacromial, and the lateral thoracic artery.
- The posterior branch, the subscapular artery, detaches from the second part of the
axillary artery.
- The lateral branches detach from the third part. They are the humeral circumflex
arteries (the frontal and the posterior one).

Anastomosesbetween the axillary artery and the subclavian artery allow the re-
establishment of circulation in case of main axillary trunk ligation. This collateral system due
to its topographical situation, is called the „periscapular arterial circle”. It is formed of:
- Subclavicular branches: the transverse cervical artery (also called the posterior
scapular artery) and the suprascapular artery.
- Axillary branches: the subscapular artery and its circumflex scapular artery (the
inferior scapular artery).
- Taking into consideration the constituion of the periscapular circle, it can be
deduced that the suppression of circulation in the axillary artery is possible above the level of
emergence of the suprascapular artery.
 The axillary vein is unique and voluminous, and accompanies the medial artery, having
the same path as it does. It collects the satellite veins that correspond to the axillary artery’s
branches, as to the superficial veins of the upper limb.
The brachial plexus is located at the top of the axilla. Here, the brachial plexus is still
constituted of its secondary truncks, and is found laterally from the axillary artery.
Afterwards, these trunks group themselves in fascicles, and are named in relation with their
position topwards the artery: the lateral, medial, and posterior fascicles. In the inferior part of
the region, the fascicles continue in the main terminal branches that are arranged as follows:
- The musculocutaneous nerve is located laterally from the artery, and accompanies
it up to the coracobrachial muscle, which it will perforate afterwards.
- The median nerve, when it is formed of the two roots, is located before the artery.
It then goes on to occupy a frontal-lateral position to it.
- The ulnar nerve descends along the medial face of the artery, between it and the
axillary vein.
- The medial brachial cutaneous nerve has the same trajectory with the ulnar nerve,
but is sometimes located on the front part of the vein.
- The medial antebrachial cutaneous nerve is postero-medially located from the
artery.
- The axillary nerve is attatched on the subscapular musclem and is found behind
the artery. Thus, its trajectory becomes dorsal towards the humerotricipital triangle.
- The radial nerve is found behind the artery.
The collateral branches come from the trunks of the brachial plexus, descend to the
walls of the axillary region, and have the following relationships with the axillary artery:
- The prearteriolar nerves: the pectoral nerves
- The retroarteriolar nerves: the subscapular nerve, the thoracodorsal nerve, and the
lateral thoracic nerve.
Axillary lymphatics.The axillary lymph nodesare grouped among the axillary vessels
(brachial/lateral, central/intermediate, and apical/subclavicular lymphocenters), or on the
walls of the region (the pectoral and subscapular group).
The axillary lymph nodes collect the lymph network of the upper limb, of the supraumbilical
territory of the trunk, and that of the breast. The subclavicular trunk detaches from the apical
nodes that pass in the lateral region of the neck.
Practical references.In order to discover the contents of the axillary pit, insertion
towards the front and posterior wall is practiced.
- In the front, the subclavicular path is followed, gradually excising the planees: the
covering, the superficial musculofascial, and the clavipectoral fascia. The axillary vascular-
nervous bundle has a superficial postion, and is not covered at this point by the small pectoral
muscle.
- Inferiorly, the approaching of the elements from the basis of the axilla is made by
excising the covering planee (skin, subcutis, axillary fascia).
- The cephalic vein, for its incannulation, is revealed in the deltoidopectoral groove.
The arm is placed in anatomical position, and the skin and the subcutaneous tissue is
sectioned. The the superficial blade of the fascia is excised, and the vein is searched in its
doubling.
- Interstitia of the front wall have a great importance, as they can become real spaces,
where pathological collections are gathered. These spaces are:
- The prepectoral space or the superficial one, which corresponds to the subcutis.
- The middle or interpectoral space that is found between the two musculofascial
planes of the front wall.
 - The deep or retropectoral space is located behind the small pectoral, and actually
corresponds to the axillary pit.

THE SCAPULAR REGION

(Regio scapularis)

It consists of the formations located behind the scapula, doubling the front wall of the
axillary region.
Limits: upwards and medial, the corresponding margins of the scapula; infero-lateral,
the inferior angle of the scapula and the inferior margin of the big round muscle; supero-
lateral, the posterior margin of the deltoid muscle.
The exterior shape: The spine of the scapula is projected by the supraspinatus and
infraspinatus fossa. In this way,the shape of the trapezius, great dorsal, and posterior margin
of the deltoid muscles are outlined.
The covering planee: The skin is thick and mobile. The subcutaneous tissue is of
variable thickness, and contains insignificant vessels, and sensitive nervous branches that
come from the supracavicular nerves of the cervical plexus and from the dorsal branches of
the first thoracic nerves.
The superficial musculo-fascial plane is composed in the upper part of the region of
the trapezius muscle, and in the inferior part of the big dorsal and the fascias that cover it.
The big dorsal passes over the inferior angle of the scapula, and is sticking it to the thoracic
wall.
Osteofibrous spaces and their contents are beneath the aforementionedplanee, and
correspond to the supra- and infraspinal fossae into which are found two spaces:
- The supraspinous space is formed by the supraspinous fossa and fascia. It contains
the following elements:
- The supraspinous muscle whose fleshy part fills the whole space; its tendinous part
passes beneath the acromion towards the humerus.
- The suprascapular artery, a branch of the subclavicular artery, enters into the
region at the upper margin of the scapula above the transverse ligament of the scapula. It is
placed under the supraspinous muscle on the boneyplanee of the space, and then passes in the
infraspinous space through the hollow from the the lateral implanetation place of the spine of
the scapula.
- The suprascapular nerve passes by the notch of the scapula, beneath the transverse
ligament, and it has the same trajectory and position with the precedent artery.
- Infraspinal space;it is formed between the boneyplanee of the intraspinal fossa and
the infraspinal fascia. These insert on the medial margin, lateral margin, and on the spine of
the scapula, and will continue laterally with the deltoid fascia.
The muscles and intermuscular spaces; the space contains the infraspinal, the big
round, and the small round muscles. The last two muscles head towards the upper extremity
of the humerus,and separate from eachother. The big round passes ahead of the scapulo-
humeral joint, while the small round passes behind it. The long head of the triceps passes
through the formed interstitial space, which delineates two spaces:
- The omotricipital, or birondo-tricipital space, is located medially; it is delineated
by the lateral side of the scapula, the two big rounds, and the long head of the triceps. It is
also called the medial axillary hiatus (Hiatus axillaris medialis), and makes possible the
communication between the axillary region and the infraspinal space; being a passage way
for the scapular circumflex artery.
 - The humerotricipital, or birondo-humero-tricipital space, is located laterally between
the long head of the triceps, the upper limit of the humerus, and the lateral parts of the two
big rounds. It is also called the lateral axillary hiatus (Hiatus axillaris lateralis), and ensures
communication between the axilla and the deltoid region. By this pathway, the axillary nerve
and the posterior humeral circumflex artery pass togetherwith their satellite veins.
The arteries of the infraspinal space; the space is vascularized by three scapular
arteries, as follows:
- the circumflex artery of the scapula arrives in that region through the medial
axillary hiatus, and descends along the lateral margin of the scapula.
- the suprascapular artery (from the subclavian artery) arrives in the space, branches
on the boney platform, and loses itself in the muscles that origin at this level.
- the posterior scapular artery (transverse cervical), a branch from the subclavian
artery, approaches the region in the upper angle, at the level of the scapula, and descends on
the medial margin of the bone covered by the rhomboid muscles.
These three arteries branch on the one side on the boneyplane of the infraspinal fossa,
and on the other intramuscular side. Like this, they are creating a wide anastomotic collateral
system, „the periscapular arterial region”, whose practical significance was described in the
axillary region.

THE DELTOID REGION

(Regio deltoidea)

This region occupies the external part of the shoulder, and corresponds to the deltoid
muscle; it has a convex, bulging aspect, due to the head of the humerus.
Limits: upwards, it is delineated by the lateral part of the clavicle, by the acromion and
by the external part of the scapula spine; downwards, by the humeral insertion of the deltoid;
anterior andposteriorly by the margins of this muscle. In its depth, it contains the
acromiocavicular and scapulohumeral joint that compose the osteoarticular plane of the
region.
The external shape; with the arm in abduction, the region has a convex shape both
vertically, and transversally. In scapulohumeral luxation, the shape of the deltoid region
changes, and it becomes angulated, looking like "shoulder epaulette".
 - In the upper part of the region, the acromion protrudes under the skin. Its shape
forms a visible angle (Angulus acromialis).
- The margins of the deltoid muscle on the skin are marked by a groove; the front
one corresponds to the deltoidopectoral groove.
The covering plane is formed of the mobile skin – less in the terminal insertion place of the
deltoid and the subcutis. Here are found the following superficial elements:
- Arteries: terminal branches of the thoracoacromial artery and of the posterior
humeral circumflex artery.
- Veins, headed towards the deltoid-pectoral groove, usually affluences of the
cephalic vein.
- The supracavicular branches of the cervical plexus in the upper side, and of the
upper lateral cutaneous nerve (from the axillary nerve) in the lateral part of the region.
- The supra acromial serous bursa (Bursa subcutanea acromialis)is located in the
subcutis, above the acromion.
The deltoid musculofascial plane is formed of the deltoid muscle and the deltoid fascia.
The deltoid fascia is thick and resistant, and it covers the external surface of the muscle. It is
sending various interfascicular septa between the muscle’s fleshy fascicles. Because of these,
the fascia’s adherence to the muscles is strong. The profound face of the deltoid muscle is
covered by a thin celulofibrous blade, which separates it from the underlying plane.
The subdeltoid planeis located between the round surface of the deltoid, and the
osteoarticular plane of the region. It is filled by a celulo-adipose tisue, which contains
periarticular tendinous and vascular-nervous formations of the region.
The periarticular tendons are located around the scapulo-humeral joint; in the front of
the subscapular tendons and the big round; upwards, the supraspinal tendon; backwards, the
infraspinal tendon and of the small round. At this level, the rounds’ tendons delineate the
humerotricipital space, which is a passage way between the axillary groove and the posterior
part of the subdeltoid space.
The serous bursae are located in the place where the tendons implant themselves (the
intraspinal, subscapular bursa and bursa of the rounds). Between the deltoid and the great
tubercle of the humerus there is a wide bursa, the subdeltoid bursa (Bursa subdeltoidea), and
between the supraspinal tendon and the acromion, the subacromial bursa (Bursa
subacromialis). Inflammation, or calcification, of these bursae results in a considerable
diminuation of the movements of the arm, especially of abduction – scapulohumeral
periarthritis.
The arteries,accompanied by two satellite veins, are tributary branches of the axillary
vessels, and are as follows:
- The thoraco-acromial artery, with the deltoid branch for the homonimous muscle,
and the acromial branch, which on the surface of the acroniom gives birth to the acromial
network (Rete acromialis).
- The front arterior circumflex artery passes beneath the common tendon of origin of
the short head of the biceps and of the coracobrachial, bypasses in front the surgical neck of
the humerus and the bicipital glide, and branches in the deltoid and in the joint of the
shoulder.
- The posterior humeral circumflex artery is thicker than the previous one. It is the
main artery of the region. It reaches the posterior part of the subdeltoid space, passes the
humerotricipital hiatus, and goes backwards, bypassing the surgical neck; it divides in several
muscular and articular branches.
Between the two humeral circumflex arteries, to the right of the surgical neck of the
humerus, an anastomotic circle called the perihumerus arterial circle is made. Superiorly, this
makes anastomoses with with the acromial network, and inferiorly, with the profound artery
of the arm. It contributes to the re-establishment of the arm’s circulation when ligation of the
main trunk is made between the emergence of the humeral circumflex arteries and the
profound artery of the arm.
The lymphatics drain in the lateral lymphocenters (brachial) and axillary nodes apicals.
The axillary nerve, located posteriorly and superiorly to the posterior humeral
circumflex artery, reaches the area by the humerotricipital space. Posteriorly, it bypasses the
surgical neck and branches in a great number of motor branches for the deltoid muscle. It
may issue a branch for the motor innervation of the small round, and the lateral cutaneous
branch of the arm, which will become superficial when it perforates the fascia at the posterior
margin of the deltoid.
Practical references; through this region,one may access the scapulo-humeral and the
acromio-clavicular joints. Preferably the incisions are made in the front part of the region.
The dorsal access is contraindicated, due to the axillary nerve being located at this level.

THE REGIONS OF THE ARM

The arm represents the free segment of the upper limb. It islocated between the shoulder
and the elbow.It is shaped as a transversally flattened cylinder, andit contains the soft
formations which are located around the humeral diaphysis.Topographically,it is divided into
anterior and posterior regions, withboth being named brachial regions.

THE ANTERIOR BRACHIAL REGION

(Regio brachii anterior)

Limits:upwards,an anterior transversal linebetween the pectoralis major's tendon, and

that of the deltoid; downwards,a transversal line situated at two fingers above the fold of the
elbow;medial and lateral,two vertical lines thateach correspond to the proper epicondyle;in its
depth,the region extends to the anterior side of the humeral body and to the two brachial
intermuscular septums.
The exterior shape:the fusiform shape of the biceps muscle protrudes in the middle of
the region delineating two grooves;a medial one and a lateral one.
-the medial bicipital groove isdeep, and extends from the armpit to the fold of the
elbow.
In the depth of this groove,the brachial artery pulsations can be palpated.
-the lateral bicipital groove issituated outside the biceps's outline.It is wider than the
previous one,and goes down from the deltoid's peak to the fold of the elbow.
The covering planeis consisted of:
-Skin;mobile and supple medially;thicker on the lateral side of the arm.
-Subcutiscontains the following superficial formations:
-the basilic vein goes up along the medial bicipital groove; in the middle of the
arm,it perforates the brachial fascia,and continues subfascially to the place where it merges
with the axillary vein.
-the cephalic vein goes up along the lateral bicipital groove,and then along the
deltoid's anterior margin to the deltopectoral groove.
-the superficial lymphatics form two networks around the previous veins, and head
to the lymph nodes's brachial group,respectively to the deltopectoral nodes.
-the cutaneous nerves come from four different sources:
-supero-external:the superior lateral brachial cutaneous nerve(axillary nerve)
-infero-external:the inferior lateral brachial cutaneous nerve(radialnerve)
 -supero-medial:the intercostobrachial nerve.
-infero-medial:the medial brachial cutaneous nerve,which becomes superficial
by perforating the fascia in the superior side of the region.
Brachial fascia; it forms a sleeve around the muscles, andsends in depth two
septums,which seperate the flexor group from the extensor group. The fascia,together with
the two brachial intermuscular septums and the bone plane,delineate an anterior osteofibrous
space,which contains the formations of region's subfacial plane. The brachial fascia,in the
middle of the arm,corresponds to the medial bicipital groove, andis perforated by the basilic
vein, whichforms a hole named ''hiatus basilicus''.
The subfascial planecontains the muscles and the region's deep vasculo-nervous
formations.
The muscles form two overlapping layers. The superficial layerconsists in the brachial
biceps, and the deep layer consists of the coracobrachialis muscle, which isplaced
medially;the brachial muscle issituated underneath the biceps, and the original portion of the
brachioradialis situated in the infero-lateral part of the region.
The brachial biceps delineate two subfacial grooves,named bicipital grooves(so the term
bicipital groove indicates the visible groove on the skin,as well as the deep grooves,which are
actually intermuscular interstitial spaces).
-The medial bicipital groove (interstitial space) (Sulcus bicipitalis medialis) is
formed between the brachial biceps's medial margin, and the triceps's antero-internal
margin.It contains the vasculo-nervous bundle of the arm, and is consisting of the brachial
artery,the brachial veins, and the median nerve.
-The lateral biciptal groove (interstitial space) (Sulcus biciptalis lateralis)is formed
between the biceps's lateral margin and the brachial muscle on the one hand,and the
brachioradialis's internal side on the other;on its inferior side,it contains the radial nerve and
the terminal portion of the deep humeral artery.
Vessels and nerves
Brachial artery (humeral) descends vertically in Sulcus bicipitalis medialis before the
medial intermuscular septum, along the internal edge of the biceps brachii, and is covered
only by the superficial plane of the region. It is between two thin brachial veins anastomosed
to each other by many transversal branches. It comes in relation with the terminal branches of
the brachial plexus (see later).
Collateral branches of the brachial artery have their origin in this region, but their path
goes outside of it:
- Deep humeral artery; it is detached in the upper part of the region, and then
directed tothe posterior brachial region.
- Superior ulnar collateral artery; it is detached in about the middle of the arm;
crosses themedial intermuscular septum, and then proceeds to the posterior region of the arm.
- Inferior ulnar collateral artery; it comes off the bottom of the region, and also
crosses
the medial intermuscular septum.
Deep lymphatics accompany the brachial vessels and collect in the brachial lymphatic
centers of the axillary nodes.
Nervesare represented by the terminal branches of the brachial plexus:
- The median nerve accompanies the brachial artery. In the upper part of the region,
the nerve is foundlaterally from from the artery, then it crosses the artery from the front, so
that in the bottom of the arm, it is placed medial from artery. On the arm it does not emit any
branch.
 - Medial forearm cutaneous nervenerve; it is also found in Sulcus bicipitalis medialis
medialis,
before the brachial artery, and then crosses the fascia through hiatus of the basilic vein to go
down on the forearm.
- Musculocutaneous nerve; it crosses obliquely coracobrachialis musclemuscle, and places
itself in theinterstitial space between the biceps and brachialis muscle, where it gives
branches for these two muscles and a branch –the forearm lateral cutaneous nerve - for
forearm.
ocated medial to the brachial artery, and has a very short
- Ulnar nerve; it is located
trajectory in this region. In the upper arm
arm, it perforates the medial intermuscular septum
septum, and
is after that passing to the posterior region of the arm.
- Radial nerve; it crosses the top of the region, and is directing itself posterolateral
posterolaterally
in the dorsal region of the arm. It thent reappearsin
sin Sulcus bicipitalis lateralis at the lower
limit of the region.
Practical references.
The discovery
covery of the brachial artery in the medial bicipital groove, where it has a
trajectory that corresponds to the line joining the bottom of axillary fossa and elbow fold,
medial to the insertion of the biceps tendon. Artery,median
Artery nerve, and the
he two brachial veins,
are encased in a fibrous
rous sheath called "the
" brachial channel" along their length.

Note that the brachial artery may bifurcate at any level of the arm, and more so, this
bifurcation may occur in the axillary region.
Brachial artery ligature can be performed above and below thee deep brachial artery
origin. In the first case, the collateral circulation is achieved by anastomoses between the
deep brachial artery and perihumeral circle. In the second case, collateral circulation occurs
between the deep brachial artery and forearm
forear arteries, via arterial network of the elbow.

POSTERIOR BRACHIAL REGION

(Regio brachii posterior)

Limits: up and down,, the lines that continue similar lines from the anterior region of the
arm; lateral and medially, vertical lines described in the previous region. InIn depth: the back of
the humeral body and the two intermuscular septa.
External form: youu can see the brachial triceps outlines; the lateral and long head of the
muscle.
Coveringplane: is formed of thick and mobile skin;; the subcutis contains branches of
posterior brachial cutaneous nerve (from radial nerve); the brachial fascia that delimits,
together with the boneyplane and the two intermuscular septa, the posterior space of arm.
 Subfascial plane consists of triceps, brachial, and the two neurovascular bundles; one
consisting of the deep brachial artery and radial nerve, and the other of the ulnar nerve and
collateral ulnar arteries.
- Triceps brachii muscle completely fills the posterior space of the arm. The three heads
are joined together in this region. They were previously separated by incomplete gaps.
- Radial neurovascular bundle, consisting of the radial nerve and deep brachial artery,
enters the anterior region of the arm - through the medial intermuscular septum perforation -
at upper end of the humeral groove for the radial nerve. Both parties are held in this groove,
which becomes a spiral musculoskeletal channel covered by long and lateral head of the
triceps. The bundle is surrounded by a loose cellular tissue, and the artery is placed above and
lateral to the nerve.
- The deep brachial artery emits the radial collateral artery inthe groove of the radial
nerve. This accompanies the radial nerve and the medial collateral artery, which enter the
triceps, and follow it down to the elbow.
- The radial nerve is found 10cm above the lateral epicondyle of the humerus, and
leaves his groove to perforate the lateral intermuscular septum. Before this, it is placed in the
lateral bicipital groove, and then continues in the anterior region of the elbow. On the arm, it
gives branches to the triceps muscle for the innervation of each portion separately, and it
willalso emit cutaneous branches as follows:
- The posterior cutaneous nerve of the arm for the skin at this level
- The inferior lateral cutaneous nerve of the arm for the innervation of the proper
territory.
These nerves detach in the radial nerve groove, and perforate brachial fascia to become
superficial.
- Ulnar neurovascular bundle consists of the ulnar nerve, and the two ulnar collateral
arteries, which are branches of the brachial artery. They arrive from the anterior region of the
arm, through the perforation of the medial intermuscular septum. Although they are located
in medial bicipital groove, behind brachial vessels, they belong to the posterior region, as it
sits behind the dividing septum.
- Ulnar collateral arteries descend on the back of the septum.
- Ulnar nerve; it descends between the septum and the medial head of the triceps in
the direction of dorsal face of medial epicondyle without issuing a branch.
The nerve’s path corresponds to a vertical line that connects the bottom of axillary fossa
to the back of the medial epicondyle.
Practical references.
Because of the relation between the radial nerve and humerus body, fractures at this
level can damage the nerve. Discovering the nerve is made between long and lateral head of
the triceps.

THE ELBOW REGIONS

The elbow is the connecting segment interposed between the arm and the forearm. It
includes the elbow joint and soft elements located around it.
It is flattened in the anterior-posterior direction, and in the anatomical position, it
forms an open angle to the outside, because the forearm’s axis in extension is not in line with
the axis of the arm. This position of the elbow is called "physiological Cubitus valgus", and
has a size of around 1700.
Topographically, relative to the osteoarticular skeleton, the elbow consists of an
anterior cubital region and posterior cubital region.
 THE ANTERIOR CUBITAL REGION
(Regio cubiti anterior)

Limits: upwards and downwards, one transversal line that passes with two fingers above
and underneath the fold of the elbow; laterally and medially, two vertical lines drawn through
the corresponding epicondyles; in depth, it extends up to the joint of the elbow.
External shape; the elbow can be explored with the forearm in flexed position (clinical
position), and with the forearm in extension and supination (anatomical and surgical
position).
- In the forearm semi-flexion, the elbow’s skin is a transversally folded to form the
fold of the elbow. It can be highlighted at the level of a transversal line that connects the two
epicondyles, and is situated at a finger width above the joint of the elbow.
- In the forearm extension, on the elbow’s flat surface, protrude three muscular
outlines. In the middle, there is outlined the brachial biceps and its tendon, which has
triangular shape and directed upside down. Laterally, the outline is given by the forearm’s
superficial extensor muscles (the lateral epicondylian muscles), and medial by the forearm’s
superficial anterior group (the medial epicondylian muscles).
- Between these three muscular outlines, is also outlined the lateral and medial
bicipital groove. Both grooves converge towards the elbow’s middle part to continue with the
forearm’s median groove. At their meeting point, a depression is formed, which is called
cubital fossa (Fossa cubitalis). By deep palpatingin the cubital fossa with the elbow in semi-
flexion,one may find the biceps tendon, and medially to it, the brachial artery pulsations.
- Under the skin appear the elbow’s superficial veins, which have a very varied
appearance.
The superficial plane or covering plane, consists of:
- Supple, mobile, transparentskin, without pilosity, so that the superficial veins can be
observed through it.
- A variable thickness ofsubcutis, which is more expressed to women and children, and
may mask the superficial veins. It contains the following superficial formations:
- Superficial veins: basilica vein, which ascends on the eminence of the medial
epicondylian muscles in the direction of the medial bicipital groove; cephalic vein, which is
located on the lateral side of the region, and is moving towards the lateral bicipital groove;
the forearm’s median vein, which is placed in the median groove of the region.
- Between these three veins, in the case of an ”M” shaped anastomosis, the
forearm’s median vein splits into two divergent vessels, the mediobasilica vein and the
mediocephalic vein, which open in the basilic and cephalic veins,respectively.
- If an ”N” shaped venous anastomosis occurs, the connection between the cephalic
vein and basilica vein is achieved through a medial vein of the elbow, which will havean
obliquely upward and medial pathway from the cephalic vein to the basilica vein. In such
cases, the forearm’s median vein becomes a tributary of it.
- Whether from the median vein of the elbow, or from the basilica vein, there will
originate a perforating branch that anastomoses with one of the deep veins.
- The superficial lymphatics from the medial part of the regionmovetowards the
cubital lymph nodes, which are superficially placed. From the lateral side of the elbow, the
lymph gets into the apical group of the axillary lymphocenters, and through the
deltoideopectorale station.
- The cutaneous nerves are distributed as follows:
- The forearm’s lateral cutaneous nerve crosses the fascia above the lateral
epicondyle, and is distributed to the side of the region.
 - The arm’s lateral inferior
i cutaneous nerve (from the radial n.) is directed to the
skin on external side of the elbow.
The fasciais
is the continuation of the brachial fascia with the antebrachial fascia. It
strongly
trongly adheres to the epicondyles
epicondyles, and is perforated in several places by the communicating
veins of the elbow. In its mediall side,
side it is thickened due to the aponeurotic expansion of the
biceps, which passes as a bridge over the lower end of the medial bicipital groove in the
shape of a fibrous blade.

The subfascial planeis comprised

comprise of the muscles and the vasculo-nervous
nervous bundles on
the front side of the elbow:
Muscles are arranged in three groups, as follows:
-The middle group, which consists of the brachial biceps and the brachial muscle.
At this level, the cylindrical tendon of the biceps is formed, and from whose medial edge
emerges detaches the muscle’s aponeurotic expansion. Between the tendon and the radial radi
tuberosity,a
,a serous bursa (bicipitoradialis bursa) is interposed.
interposed. The brachial muscle is situated
more profoundly between the he biceps and humerus.
-The
The medial muscular group (medial epicondylian muscles) consists of six muscles
arranged in three overlapping layers, and is represented by:
- The round pronator, the radial flexor of the carpi, the long palmaris, the ulnar
flexor of the carpi (superficial layer).
- The superficial flexor of the fingers (middle layer).
- The deep flexor of the fingers (deep layer).
-The
The lateral muscular group (laterally epicondylian muscles) comprises four
overlapping muscles: the brachioradial muscle,
muscle, the long radial flexor of the carpi, the short
radial flexor of the carpi, and the supinator muscle.
The three muscular
cular groups together delineate two convergent interstitial spaces,
space called
the lateral and medial bicipital groove.
The medial vasculo-nervous
nervous bundle is placed in the medial bicipital groove, andconsists
of the brachial artery and the median nerve bifurcation.
-The brachial artery lies between the medial edge of the biceps tendon and the round
pronator muscle, and covered by the bicipital aponeurosis. About two cm above the fold of
the elbow, it bifurcates into the radial artery and the ulnar artery.
-The radial artery descends between the brachioradial muscle and pronator teres teres,
placed on the supinator muscle. At this level, it issues the radial recurrent artery that ascends
toward the lateral bicipital groove, and crosses the biceps tendon.
-The ulnar artery descends in depth, in oblique and medial direction, under the
medial epicondylian muscles, and sits on the profound flexor of the fingers. Right after its
origin, it issues the the ulnar recurrent artery and the common interosseous artery; the latter
splits into an anterior and posterior interosseous artery.
-The median nerve descends medially on the brachial artery, passes in depth
between the two heads of origin of the round pronator. It crosses frontally the ulnar artery,
and then will be placed on the midline of the forearm covered by the flexor superficial flexor
of the fingers. At the level of the elbow, it issues muscular branches for the forearm’s flexors.
The lateral vasculo-nervous bundle of the elbow is situated in the lateral bicipital
groove. It consists of the radial nerve and arteries:
-The radial nerve is situated between the brachioradial, followed by the long radial
extensor muscle of the carpi, and the brachial muscle in the depth of the lateral bicipital
groove at the anterior of the intermuscular septum. Somewhat above the articular line, it splits
into a superficial sensory branch, and another deep motor branch. The superficial branch
remains anterior, and descends underneath the brachiradial’s medial edge. The profound
branch is thicker, and descends in a posterior direction to spirally bypass the upper extremity
of the radius. Moving laterally of bone, it passes the supinator’s fascicles to reach the
forearm’s posterior region.
-The lateral bicipital groove’s arteries are: the radial collateral artery (the terminal
branch of the profound brachialis) and radial recurrent artery (from the radial artery). These
two vessels anastomose with each other to form a preepicondilian arch that intervenes in the
collateral circulation between the arm and forearm.
Practical references.
The elbow’s superficial veins are preferred for venipuncture and cannulation. This is
especially true of the cephalic vein, because the basilica vein is very close to the elbow’s
medial vasculo-nervous bundle, and is separated from it only by the bicipital aponeurosis.
The brachial artery is revealed at the level of the fold of the elbow, medial to the biceps
tendon. This is a major landmark (internal bicipital pathway). The artery ligation at this level
is possible due to the collateral circulation between the arm and forearm arteries, through the
elbow’s arterial network, to which we shall return. We mention that at this level, the median
nerve is located internally within 1 cm of the brachial artery.
The profound branch of the radial nerve has intimate relations with the joint of the
elbow. The nerve passes on the front of the humeroradial joint,and enters the supinator’s
interstitial space (Canalis supinatorius) at about 2 cm below the articular interline. The nerve
positioning is different in pronation and supination. Therefore, in forced pronation it is
moving away from the humero-radial nerve line, while in supination, it is approaching to it.
With these considerations in mind, the interventions on the external face of the elbow are
made with the forearm in forced pronation in order to remove as much as is possible in the
surgical field.

THE POSTERIOR CUBITAL REGION

(Regio cubiti posterior)

Limits: upwards and downwards, the prolongation of the two transversal lines from the
anterior face of the elbow; medial and lateral, the vertical lines placed on the corresponding
epicondyles; in depth, it extends up to the osteoarticular plane of the region.
External shape.
 - In extension, the olecranon protrudes dorsally as a quadrangular outline; Also, the
epicondyles can be seen and palpated. In this position, the olecranon’s tip is located on the bi-
epicondylian line, and is somewhat closer to the medial epicondyle.
- In flexion, the olecranon’s peak descends below the biepicondylian line, and forms
an isosceles triangle between the three boney prominences
- On the olecranon’s sides, between it and the corresponding epicondylies, are
formed two longitudinal depressions, called the paraolecranian grooves. In the depth of the
medial paraolecranian groove, the ulnar nerve is located, and if pronation and supination
movements are made on the forearm, the radial head can be palpated in the lateral
paraolecranian groove’s depth.
- There can be seen a transversal depression above the olecranon, named the
supraolecranian groove. In its depth, the triceps tendon can be palpated.
The superficial plane consists of:
- Thick and very loose skin, which in extension has many transversal folds that will
smooth out in flexion. This excess of skin represents the skin’s reserve, necessary for the
flexion movement
- Thin subcutis that contains a serous bursa (Bursa subcutaneous olecrani), and
cutaneous branches coming from the cutaneous nerves – lateral inferior of the arm, lateral of
the forearm, posterior of the arm, posterior of the forearm, medial of the arm, and medial of
the forearm.
-Thefascia is adherent to the epicondyle, olecranon, and the posterior face of the
ulna.
The subfascial plane contains the muscles and the vessels of the region and the ulnar
nerve.
The muscles form three groups, namely:
-The middle group is formed by the triceps insertion on the olecranon. Between
them, a subtendinous bursa is interposed that frequently communicates with the articular
cavity.
-The lateral group, formed by lateral epicondylian muscles: anconeus, ulnar
extensor of the carpus, the small finger extensor, and the extensor of the fingers.
-The medial group is composed of the medial epicondylian muscles, the ulnar flexor
of the carpus with its two origin heads, and the ulnar nerve groove of the humerus, which
delineate a musculoskeletal orifice for the passage of the ulnar nerve.
The region’sarteries,from behind the elbow joint, form an extensive retroepicondylian
and retroolecranian anastomotic system, called the elbow joint arterial network (Rete cubits).
The arteries that enter into the constitution of this network are:
-Descending branches: being represented by the collateral arteries, they are are four
in number. Namely, the upper and lower collateral ulnar arteries (from the brachial artery),
and the medial and radial collateral arteries (from the profound brachial artery).
-Ascending or recurrent branches come from the forearm arteries, namely: radial
recurrent artery, ulnar recurrent artery, and interosseous recurrent artery. These three arteries
participate in the formation of the arterial network, especially by their posterior branches. In
the case of the brachial artery, ligation at the level of the elbow, the collateral circulation
toward the forearm will be easily restored, because of this anastomotic network.
-The ulnar nerve departs from the posterior face of the medial intermuscular septum,
and descends in the direction of the medial paraolecranian groove. Here, it passes through the
musculoskeletal orifice formed by the ulnar nerve groove and the two heads of the flexor
carpi ulnaris. At this level, it may be covered by a transversal fibrous strip
(epitrohleoolecranian strip) stretched over the nerve’s groove, between the olecranon and the
medial epicondyle.
 Practical references. In elbow fractures and dislocations, the previously described
isosceles triangle will be modified. The ulnar nerve can be easily injured in medial
epicondyle fractures, and is easily discovered through a vertical incision in the medial
paraolecranian groove.

THE FOREARM REGIONS

Topographically, the forearm is the segment between the elbow and wrist. It
corresponds to the diaphysis of the radius and ulna, which form, together with the
interosseous membrane, the osteofibrous plane of the forearm’s regions.
Viewed in supination, the forearm has a flattened shape in the antero-posterior
direction, with a greater transverse diameter in its upper extremity, due to the presence of
muscles.
There are delimited two regions on the forearm, called the anterior antebrachial
region, and the posterior antebrachial region.

THE ANTERIOR ANTEBRACHIAL REGION

(Regio antebrachii anterior)

Limits: upwards, a transversal line located two fingers below the fold of the elbow;
downwards, a transversal line placed above the ulna’s head; laterally and medially, by a line
joining that epicondyle with the styloid’s apophysis on the same side; in depth, the region
extends up to the osteofibrous skeleton of the forearm and lateral intermuscular antebrachial
septum.
External shape: In the upper regionis seen the outline of medial and lateral
epicondyle’s muscles, between which is placed a vertical groove, called the medial
antebrachial groove.At the bottom of the region, with the forced flexion of the hand, protrude
the superficial muscular tendons, whichare placed in latero-medial direction as follows: the
flexor carpi radialis tendon, the tendon of the palmaris longus,and the flexor carpi ulnaris
tendon. In the external part of the region is outlined the brachioradial muscle. Between the
brachioradial’s and flexor carpi radialis tendons, in the lower part of the region, there is
delimited an elongated groove, called the radial’s groove, or the pulse’s groove, where the
radial artery pulsations can be perceived. Through the skin can be observed the superficial
veins, which exhibit an extremely varied trajectory.
The covering plane is formed of thin skin, which is mobile and hairy on the lateral part
of the region; the subcutis has a varying thickness, with the following elements:
- The superficial veins: cephalic, basilica, and median veins of the forearm, which are
joined bynumerous anastomoses.
- Superficial nerves are branches ofthe lateral cutaneous nerve of the forearm, and the
medial cutaneous nerve of the forearm for the corresponding half of the skin. They are
interconnected.
Antebrachial fascia surrounds the forearm’s flexors; deeply, it sends the intemuscular
lateral septum; medially, it is adherent to the posterior edge of the ulna, so that the forearm’s
medial intermuscular septum is missing or poorly developed. The fascia and the skeleton are
delimiting an osteofibrous space for the muscles and the subfascial formations of the region.
The subfascial plane contains several muscular layers, and in their interstitial spaces are
located the vasculo-nervous bundles of the region.
The muscles are four layers as follows:
-First layer: Musculus brachioradialis, Musculus pronator teres, Musculus flexor
carpi radialis, Musculus palmaris longus, Musculusflexor carpi ulnaris.
 -Second layer: Musculusextensor carpi radialis longus, Musculus flexor digitorum
superficialis.
-3rd layer: Musculusextensor carpi radialis brevis, Musculusflexor pollicis longus,
Musculusflexor digitorum profundus.
-4th layer: Musculuspronator quadratus, Musculussupinatorius.
In the lower part of the region, the first three muscular layers become tendinous. The
vasculo-nervous bundles, located in the intermuscular interstitial spaces at this level, become
more superficial, and attach to the tendons.Among the forearm’s interstitial spaces, of
particular importance is the interstitial space between the third muscular layer and the
pronator quadratum, called "Pirogov-Parona’s space”. Here end the synovial sheaths of the
hand.
- The radial vasculo-nervous bundle is formed by the radial artery and the
superficial branch of the radial nerve, and is located at the side of the region. It is covered by
the medial edge of the brachioradial muscle, whichis its satellite.
-Radial artery, accompanied by two radial veins in the upper part of the region,
has an oblique path. It then descends vertically up to the lower third of the region. Here, it is
placed on the square pronator, and it sits in the pulse’s groove delimited by the
brachioradial’s tendons and the radial flexor of the carpi’s tendons. It is covered only by the
superficial plane of the region.
-The superficial branch of the radial nerve descends along with the artery, and is
laterally to it. In the lower third of the forearm, it drops out of the region and passes on the
posterior side, underneath the brachioradial’s tendon.
The ulnar vasculo-nervous bundle is formed by the ulnar artery and ulnar nerve, and
is located in the medial part of the region, between the superficial and the profound flexor of
the fingers.
- The ulnar artery is accompanied by two satellite veins. In the upper part of the
region, is oriented medial-downward (skew segment). It is placed deeply underneath the
medial epicondyle’s muscles. At this level, it crosses prior to the median nerve, which passes
laterally of it. It descends vertically (vertical segment) in the interstitial spaces between the
superficial flexor muscle of the fingers and ulnar flexor of the carpus on one side, and the
profound flexor muscle of the fingers on the other. In the lower part of the region it becomes
superficial, and is placed laterally to the ulnar flexor’s tendon of the carpus.
- The ulnar nervepasses by a forward inflection from the posterior region of the
elbow to the anterior region of the forearm, underneath the ulnar flexor of the carpus. In the
upper part of the forearm, it is attached to the ulnar vessels, and lies medial to them. It
accompanyies them to the wrist.
The median bundle consists of the median nerve and a thin arterial branch (median
artery) of previous interosseous one. It occupies the median axis of the forearm.
- The median nerve, after crossing the ulnar artery, descends vertically in the
interstitial spaces between the superficial and profound flexor muscles of the fingers. At the
lower part of the region is becomes increasingly superficial, and is placed in a groove
between the radial flexor’s tendon of the carpi and the palmaris longus tendon.
The interosseous vasculo-nervous bundle consists of anterior interosseous artery,
and anterior interosseous nerve (the profound branch of the median nerve). It is placed
deepest on the anterior side of the interosseous membrane, and will descend vertically on it.
The bundle tract corresponds to the interstitial spaces between the profound flexor muscle of
the fingers and the long flexor of the pollicis. Usually, the artery is placed medial to the
nerve.
Practical references .
- Radial artery is projected on the surface, along the line which connects the middle
part of the fold of the elbow with the pulse’s groove. It is discovered usually in this groove,
where it has a superficial position.
- Ulnar artery is projecting on the skin as it follows:
- The skew segment corresponds to a line which connects the mid part of the fold of
the elbow with the inner edge of the forearm, between the upper third and the middle part of
it. The artery can not be discovered at this level, because of the deep position it has.
- The vertical segment corresponds to a line joining the medial epicondyle to the
pisiform bone. The ulnar artery and the ulnar nerve can be discovered at the lateral edge of
the ulnar flexor of the carpi.
- The median nerve is accessible at the bottom of the region, where it is situated below
the coverage plane,, between the radial flexor tendons of the carpi and long palmari’s.

THE POSTERIOR ANTEBRACHIAL REGION

(Regio antebrachii posterior)

Limits:: correspond to those of anterior antebrachial

a region. The
he transversal lines being
extended posterior.
External shape. On the surface,
surface there are projected the protrusions of the forearm’s
superficial posterior muscles, and laterally-inferior,
laterally there are also observed the protrusions of
the long abductor muscle and the short extensor of the pollicis. One can also fee feel the edge
and the posterior side of the ulna that protrudes under the skin.
The superficial plane
- The skin is thick and hairy.
- The subcutis – there is a rich venous network, that continues from the back side of
the hand, and is moving towards to the anterior region of the forearm, toward the basilica
and cephalic veins. Sensitive innervation of the skin comes from the posterior, lateral lateral, and
medial antebrachial cutaneous nerves.
Antebrachial fascia; it is strong, and adheres
eres to the rear face of the ulna’s periosteum. It
delimits, along with the lateral intermuscular septum and skeletal plane,, the forearm’s
posterior space for the extensor muscles.

Subfascial plane contains the muscles and the posterior interosseous vascular
vascular-nervous
bundle of the region:
 The region’s muscles are disposed into two layers. From lateral to medial they are as
follows:
-The
The superficial layer: Musculusextensor digitorum, Musculusextensor extensor digiti
minimi, Musculusextensor
extensor carpi ulnaris.
-The deep layer: Musculus supinatorius, Musculusabductor abductor pollicis longus,
Musculusextensor
extensor pollicis brevis, Musculusextensor pollicis longus, Musculusextensor
Musculus
indicis.
The muscular tendons that towards the pollices have an oblique (down down and out)out
direction, and cross the radial extensor tendons of the carpi, which are located deeper.
The posterior interosseous vascular-nervous
vascular bundle consists of the homonymous artery
and vein. It is situated in the interstitial space between the two muscular layers, comes down
the median axis of the region, and becomes more profound.
-The
The posterior interosseous artery enters the region above the interosseous
membrane. At this level, it gives the recurrent interosseous artery. It descends
escends to the wrist.
-The
The posterior interosseous nerve, the terminal profound
profound branch of the radial nerve,
is found in the region at the lower edge of the supinator. Throughout its path, it gives
muscular branches for the deep muscles
mu of the region.

THE WRIST REGIONS

The wrist is the narrowed

rowed segment of the upper limb that connects the forearm and
hand. It corresponds the radio-carpal
carpal joint,
joint and to the soft tissues around it. It is ccomposed of
numerous tendonsons and vasculo-nervous
vasculo bundles that pass to the hand. The he wrist is of
particularly great anatomo-surgical
surgical importance.
Topographically, there are distinguished two carpian regions that are arranged
anteriorly and posteriorly relative to the central osteoarticular plane.

THE ANTERIOR CARPAL REGION

(Regio carpi anterior)

Limits: upward, a transversal line above the ulna’s head; downward, a transversal line
that passes over the pisiform bone and the scaphoid tubercle; laterally
lateral and medial
medially, two
vertical lines placed on the outer edge of the radius, and respectively the ulna; in it’s depth, it
extends to the articular plane of the region.
External shape. Through the skin can be seen a rich venous network.The skin presents
three transversal folds, which disappear into the hand’s extension.These folds are benchmarks
for the approach of the osteoarticular plane, namely:
- Superior fold; passing through the ulna’s head.
- Middle fold; corresponding the radiocarpal joint line.
- Lower fold; approximately situated at the level of mediocarpal joint line.
Between the outlines of the superficial flexors tendons, there are delimited three
longitudinal grooves, as follows:
- Radial groove, or pulse’s groove, which is found between the brachioradial’s
tendon and the carpi radialis flexor’s tendon.
- Median groove, which is found between the carpi radialis flexor’s tendon and that
of palmaris longus; in its depth, one can find the median nerve.
- Ulnar groove, which is between the carpi ulnaris flexor’s tendon and superficial
flexor’s tendon of the fingers, into which is located the ulnar vasculo-nervous bundle.
Covering plane.
- The skin is thin, mobile, and forms the aforementioned folds.
- The subcutis is poorly represented at this level, and contains a rich venous network
from whom will emerge the median vein of the forearm. The cutaneous nerves are coming
from the lateral and medial cutaneous nerve of the forearm. Respectively, from the palmar
branches of the median nerve.
- The region’s fascia is thin and is part of the antebrachial fascia who gets lost in the
flexors’s retinaculum.
- The flexors’s retinaculum is a strong fibrous formation, which is composed of
transversal fibers that are both superficial and deep. The latter having a ligamentous aspect. It
has a width of 3-4 cm, and is inserted medially and laterally on the corresponding eminences
of the carpi. It turns the carpal groove into an osteofibrous channel, called the carpal channel
(Canalis carpi), through which pass a part of the tendinous and vasculo-nervous formations
from the forearm on the palm.
The retinaculum sends into the depth of the region a septum, which is fixed on the scaphoid
and trapezium’s palmar side. Like this, as the carpal channel divides in awider internal
osteofibrous tunnel, and an narrower external one.
- The tendinous plane consists of four overlapping layers, which largely continue the
homonymous layers on the forearm.
-First layer: Musculusbrachioradialis, Musculusflexor carpi radialis,
Musculuspalmaris longus, Musculusflexor carpi ulnaris.
-Second layer: Musculusflexor digitorum superficialis.
-3rd layer: Musculusflexorpollicis longus, Musculusflexor digitorum profundus.
-4th layer: Musculuspronator quadratus; it is present only above the carpal
channel.
Regarding the ratio of these muscles, we mention:
- The brachioradial muscle and ulnar flexor’s of the carpi are inserted on osseous
surfaces that are not included in this retinaculum.
- The long palmaris gets lost through the retinaculum fibers and continues to the
palmar aponeurosis.
- The radial flexor’s tendon of the carpi, is the only tendon of the first layer passing
through the carpal channel into the lateral tunnel of it. Due to the conformation of the osseous
plane, the tendon is situated sideways, and also has a relatively superficial position.
 -The 2nd and 3rd layers’s tendons pass through the broader (wider) medial tunnel of
the carpal channel, where a total of 9 tendons are piled along with the median nerve. Due to
the high practical importance (sectioning of tendons), ), we’ll refer more extensively to the
arrangement of the tendons.
The superficial flexor’s tendons of the fingers are overlapped in two layers.
-The
Superficially, there are the tendons intended for the medius and the ring fingerss; underneath,
there are the tendons for index and little finger
fingers.
-The deep flexor tendons of the fingers,
fingers and the long flexor’s tendon of the pollicis,
are juxtaposed
sed underneath the previous layers in the
th order of the fingers.
-The
The carpal channel’s tendons are surrounded by synovial sheaths, which are
continued above the anterior annular ligament (flexor retinaculum) to the Pirogov
Pirogov-Parona’s
space. Through the canal pass two synovial sheaths: the lateral digito-carpal
carpal synovial sheath
sheath,
which isarranged around the long flexor’s tendon of the pollicis;
pollicis the common medial digito
digito-
carpal synovial sheath, which is located around the superficial and profound flexors’s tendons
of the fingers.

The vascular and d nervous pedicles of the region continue the corresponding bundles
from the anterior region of the forearm, namely:
-Radial artery;; it is located in the pulse’s groove, leaves the region at the level of
the styloid apophysial base,, and passes dorsally into the posterior region of the carpus. On the
frontal face of the wrist, it issues the palmar branch of the carpus, which anastomoses with its
counterpart
ounterpart on the opposite side to form the palmar network of the carpus on the palmar
surface of the radio-carpal al joint. Before passing dorsally,
dorsa , the radial artery emits the
superficial palmar branch, which continues in the radial groove, crosses the flexors’s
retinaculum, and reaches the hand.
 The ulnar vasculo-nervous
nervous bundle passes laterally to the pisiform
m bone, and crosses
the flexors’s retinaculum fascicles. At this level, between the retinaculum and pisiform bone bone,
an osteofibrous tunnel is formed
formed, called "Guyon's space", for the passage of the vasculovasculo-
nervous bundle.
- The ulnar artery is accompanied by two veins, and before
efore moving to the palm,
it emits the palmar branch of the carpus and a deep palmar branch in order to form the
palmar arch of the carpus and the deep arch of the palm.
- The ulnar nerve is located medially to the artery, and it divides into a
superficial branch at the level of the pisiform, which continues the nerve’s pathway on the
palm. It also emits another profound motor branch that accompanies the deep palmar artery.
The median nerve descends into the interstitial space between
een the long palmaris and
the radial flexor’s tendon of the carpi. It then crosses the carpal channel before the tendon of
the index and the superficial flexor, and is found laterally to the other tendons of this muscle.
Already in the carpal channel, it ddivides
ivides into three terminal branches intended for the fingers;
it also emits a muscular branch for the thenar muscles, which is a branch that usually crosses
the annular ligament.
Practical references. Frequently exposed to trauma, and represents a key region. The
notions of topographic anatomy are of particular importance.
importance First of all,, this is because the
the fingers tendonous unit passes here,here as well as the two nerves that provide the hand’s
sensitivity.
For the aforementioned reasons, we consider it necessary the synthesis of the
formations that pass through the carpal channel and flexors’s retinaculum.
- Flexors’s retinaculum is crossed by:
- Ulnar vasculo-nervous
nervous bundle.
- Superficial palmar branch of the radial artery.
- Thenarian motor branch of the median nerve.
- Long palmari’s tendon expansion.
- Through the carpal channel pass:
- Muscles’s tendons of :
- M. flexor carpi radialis.
radialis
- M. flexor digitorum superficialis.
- M. flexor digitorum profundus.
- M. flexor
xor pollicis longus.
- Digito-carpal
carpal synovial sheaths.
- Median nerve (not to be confused with tendons!).
 THE POSTERIOR CARPAL REGION
(Regio carpi posterior)

Limits: upwards and downwards, it is delineated by the transversal lines; laterally and
medially, the vertical lines described to the anterior region of the wrist; in its depth, it extends
up to the posterior surface of the osteoarticular plane.
External shape: there can be observed the tendonousoutlines, and in forced abduction of
the pollicis, at the base of the thumb, an oval depression called "the anatomical snuff
box".This is laterally delineated by the long abductor and short extensor tendons of the
pollicis, and medially delineated by the long extensor tendon of the pollicis. Into it’s
depth,one may perceive the radial arterial pulsations, the styloid apophysis of the radius, the
scaphoid, and the trapezium.
In the medial part of the region can be palpated the head and the styloid apophysis of
the ulna, which located 1 cm higher than that of the radius.
The line of the radiocarpal joint can be perceived through flexion and extension
movements of the hand.
The superficial plane: the mobile skin is doubled by a thin subcutis. It contains a venous
network (continuation of the dorsal network of the hand) from which the cephalic vein and
the basilica vein form. The subcutaneous nerves are coming from the posterior, medial, and
lateral antebrachial cutaneous nerves. Through the subcutis, toward the dorsal face of the
hand, pass the following: laterally, the superficial branch of the radial nerve; medially, the
dorsal branch of the ulnar nerve.
Extensors retinaculum is outbudding of the antebrachial fascia. It has the shape of a
fibrous strip, which is fixed on the carpal edges. From the profound surface of the
retinaculum, fibrous septa penetrate towards the skeleton, and attatch the radius to form six
osteofibrous tunnels, which act as crossing places for the extensorial tendons.
Tendinous plane: Osteofibrous tunnels, which are numbered in a latero-medial
direction, and contain the following tendons:
I. Musculusabductor pollicis longus, Musculusextensor pollicis brevis
II. Musculusextensor carpi radialis longus, Musculusextensor carpi radialis
brevis
III. Musculusextensor pollicis longus
IV. Musculusextensor digitorum with 4 tendons, Musculusextensor indicis
V. Musculusextensor digiti minimi
VI. Musculusextensor carpi ulnaris
The first and the 3rd tunnel’s tendons, delineate together the anatomical snuff box,
which lined in its depth by the 2nd tunnel’s tendons.
At this level, the tendons are surrounded by synovial sheaths. There one sheath for each
tunnel. Relative to the number of tendons, the sheaths may singular, or shared (common
synovial sheath in the tunnel I, II and IV). The synovial sheaths begin above the retinaculum,
and continue downwards until the half-metacarpals.
The vascular plane is profoundly situated, and consists of the radial artery, the dorsal
carpal network, and the respective accompanying veins.
-The radial artery leaves the pulse’s groove, bypasses the styloid apophysis of the
radius, after which it descends obliquely and postero-laterally. It crosses the anatomical snuff
box’s bottom, underneath the tendons intended for the pollicis, and then crosses the first
interosseous space to reach the palm. The dorsal carpal branch is found on the snuff box
bottom.
-The dorsal branch of the carpus consists of the two dorsal carpal arteries (coming
from the radial and ulnar artery), and is located on the dorsal radio-carpal joint. Here,the
posterior and the anterior interosseous artery terminate. The latter passes dorsally through the
interosseous membrane, at the upper limit of the region.
-The carpal network issues the dorsal metacarpal arteries separately for each
interosseous space.
Practical references. The region is the place of the synovial cyst that develops from the
synovial sheaths of the tendons, which often communicates with the radiocarpal joint cavity.

HAND REGIONS

The human hand, and its fingers, represents a distinctive territory, due its ability to
perform work. From the anatomical point of view, it is topographically divided into "the hand
itself", consisting of the palm (Palma manus), back of the hand (Dorsum manus) and
fingers (Digital manus). The wrist may be considered as a "hand root".
In relation to the osteoarticular central plane, the hand is divided into four regions,
namely: palmar region, dorsal and finger regions (anterior and posterior).

THE PALMAR REGION

(Palma manus)

Limits:superiorly, the inferior plica of the anterior carpal region; inferiorly, the palmar
digital plicae; laterally, two vertical lines along the margins of the metacarpal bones I and V.
The external shape. The palm presents a series of proeminences and folds:
- Eminences:
- The thenar eminence in the lateral part of the palm is made by the shape of the
thenar muscles.
- The hypothenar eminence in the medial part of the palm; it is more
highlighted, and it is made by the shape of the hypothenar muscles.
- The talon of the hand is the elevation from the proximal part of the palm where
the thenar and hypothenar eminences meet.
- The palmar digital eminences at the base of the last four fingers; they are
separated by small depressions.
- In the center of the palm between these proeminences a large depression is formed
called „the back of the hand” or „Poculum Diogenis”.
- Plicae:
- The superior palmar plica (Plica palmaris superior), or „the vital line”, is a
curved line around the thenar eminences until the lateral margin of the hand. It appears as a
consequence of the opposability of the thumb.
- The middle palmar plica (Plica palmaris media), or „the cephalic line”,
crosses the middle of palm obliquely, and makes a concave curve oriented upwards. It
represents the flexion line of the last four fingers.
- The inferior palmar plica (Plica palmaris inferior), or „the line of the heart”,
is situated at the root of the last three fingers, transversally and concave oriented downwards.
It represents the line made by the simultaneous flexion of the last three fingers.
- The palmar digital plicae are situated at the root of the fingers; they extend
towards the interdigital spaces as the interdigital plicae or comissuras.
The covering plane is made out of skin, subcutaneous tissue, the aponeurosis, and the
superficial fascias of the palm.
- The skin is thick, lacks pilosity, is rich in sudoriparous glands, and it is adapted to
prehension. It is adherent to the underlying layer, and has some mobility only at the level of
the thenar and hypothenar eminences. The skin of the palm has a reduced quantity, and is
without excess in case of loss of tegument. The skin presents numerous plicae correlated with
the movements of the articulation of the hand which act as articulations of the tegument that
allow various movements of the segments of the hand. Since they are functional plicae, their
integrity is considered when incisions are made on the palm.
- The subcutaneous tissue has an areolar structure, with the exception being the thenar
eminence. It is crossed by numerous fibrotic ties placed vertically from the dermis to the
palmar aponeurosis. Its purpose is to fix the skin to the underlying layer. These ties
compartmentalize the cellulo-adipose layer into small pelotas that are held under pressure.
This gives the palm its necessary elasticity. The honeycomb shaped structure of the
subcutaneous tissue allows the propagation of the infections to the profound layers.
The subcutaneous tissue of the palm communicates with that of the anterior face of
the fingers, and through the interdigital spaces, with the subcutaneous tissue of the back of
the hand. It contains:
- M. palmaris brevis in the hypothenar eminence.
- Small arteries from the superficial palmar arch which perforates the aponeurosis.
- The superficial venous network followed by a vast lymphatic network.
- The cutaneous nerves: the palmar branch of the median nerve innervates the
tegument of the lateral two thirds of the palm; the palmar cutaneous nerve from the ulnar
nerve for the skin of the hypothenar; the superficial branch of the radial nerve for the external
superior part of the thenar.
The palmar aponeurosis has the shape of a triangular fan in the middle of the palm,
and acts as a continuation of the tendon of the palmaris longus muscle. Towards the
interdigital spaces, the fascicles of the aponeurosis form fibrotic arches placed in two rows; a
proximal and a distal row, which delineate 4 windows. Through these windows the lumbrical
muscles, together with the proper vascular-nervous package of the fingers, pass towards the
root of the fingers. Along the lumbrical muscles, a communication between the subcutaneous
tissue and the profound conjunctive spaces of the palm is formed. These communications are
called „lumbrical canals”. The palmar aponeurosis is completed laterally and medially by the
thenarian and the hypothenarian fascias. These thin fascias cover the muscles of the two
eminences, and they are continued by the dorsal fascia of the hand.
The palmar spaces start between the superficial fascial-aponeurotical layer, and the
profound palmar or interosseous fascia, which covers the palmar face of the metacarpal bones
and the interosseous spaces. The lateral palmar septum (fixed on the anterior margin of the
IIIrd metacarpal bone), and the medial palmar septum (inserted on the Vth metacarpal bone)
delimit on the thenar and the hypothenar space. They also delineate together a 3rd space - the
midpalmar space.
- The thenar space is situated external to the lateral palmar septum, and is isolated from
the other palmar spaces; it communicates along the tendon of the flexor pollicis longus
muscle with the Pirogov-Parona space of the forearm. It contains:
- The muscles of the thenar divided into 3 layers:
-The superficial layer: Musculus abductor pollicis brevis.
-The mid layer: Musculus flexor pollicis brevis with its origin parts which
form a muscular tunnel where the tendon of the long pollicis muscle passes; Musculus
opponens pollicis.
-The profound layer: Musculus adductor pollicis.
- The lateral digito-carpal synovial sheath covers the tendon of the flexor pollicis
longus muscle.
- Vessels and nerves:
-The superficial palmar artery crosses the abductor pollicis brevis muscle, and
heads towards the midpalmar space.
 -The motor thenarian branch of the median nerve is placed between the abductor
brevis muscle and the opponens pollicis muscle.
- The hypothenar space is situated internally to the medial palmar septum; it
communicates through small orifices with the interstitial space of the forearm and with the
midpalmar space. It contains:
- The muscles of the hypothenar place into two layers:
- The superficial layer: Musculus abductor digiti minimi and Musculus flexor
digiti minimi.
- The profound layer: Musculus opponens digiti minimi.
- The profound ulnar vascular-nervous package is made out of the profound palmar
artery and the profound motor branch of the ulnar nerve; it crosses the hypothenar eminence,
and after it perforates the palmar fascia, it crosses into the interosseous space.
- The midpalmar space,or „the palmar canal”, is situated underneath the aponeurosis
between the two palmar septums. It communicates widely through the carpal tunnel with the
conjunctive interstitial space of the forearm. Also, it communicates through the lumbrical
canals with the superficial conjunctive spaces of the hand, and with the roots of the fingers.
The space contains:
- The midpalmar tendons: after they exit the carpal tunnel, they remain grouped and
in the inferior part of the space which they divide. The tendons of the flexor digitorum
superficialis muscle overlap those of the flexor digitorum profundus muscle together with the
lumbrical muscles.
- The common digito-carpal synovial sheath includes the tendons of the superficial
and the profound flexor digitorum muscles. For the tendon of the digitus minimus, the
synovial sheath continues without interruptions on the finger. For the tendons II-IV, the
sheath is interrupted at the middle of the palm, and there are proper digital sheaths starting at
the metacarpophalangeal line. Between the two rows of tendons (superficial and profound),
there is a synovial sac, so that even though they have the same synovial sheath, they remain
separated.
- The midpalmar spaces. The tendons divide the space into two conjuctive spaces:
-The pretendinous space between the palmar aponeurosis and the tendons. It
contains the subaponeurotic vascular-nervous layer of the hand.
-The retrotendinous space between the tendons and the profound palmar
fascia. It contains lax conjuctive tissue and is continued with that of the Pirogov-Parona
space.
- The pretendinous vascular-nervous layer is represented by the superficial palmar
arch and by the nerves for the fingers.
-The superficial or subaponeurotic palmar arch is made out of the ulnar artery
and the superficial branch of the radial artery, which anastomose next to the IInd
intermetacarpal space. The ulnar artery is the main component of the arch, and has two
segments: an oblique one that descends laterally, and a transversal one, which corresponds to
the arch (in the middle of the palm it makes a convex curvature that is oriented downwards).
-From the convexity of the arch arise 4-5 common digital palmar arteries,
which head towards the root of the fingers, and split next to the windows of the palmar
aponeurosis into proper digital arteries (collateral arteries). At their splitting point, they
anastomose with the palmar metacarpal arteries, which come from the profound palmar arch.
-The palmar arch is followed by two venous arches, which continue as the
ulnar veins, and as the subaponeurotic lymphatic network of the palm.
-The median nerve is divided into three common palmar digital nerves. From
here, there will arise seven proper palmar digital nerves. The nerves are situated underneath
the superficial arch in the intervals between the tendons of the flexor digitorum superficialis
muscle.
-The
The superficial branch of the ulnar nerve is situated in the medial part of the
pretendinous space; it divides into three proper palmar digital nerves. The two branches are
destined for the auricular cross in the hypothenar space. It also gives a communicating branch
(anastomotic branch) with the median nerve.

- The interosseous space, or the profound palmar space,

space is osteofibrotic, and iis formed
between the profound palmar fascia and the skeletal layer of the palm. It contains the
interosseous muscles and a vascular
vascular-nervous package.
- The interosseous muscles are placed into two rows (palmar and dorsal) that
obstruct the intermetacarpal spaces. Also in this space,
space is the origin of the transversal head of
the adductor pollicis brevis muscle.
- The vascular-nervous
nervous package is made out of the profound palmar
palmar arch and the
profound branch of the ulnar nerve.
-The
The profound palmar arch is placed underneath the profound palmar fascia,
between this fascia and the superior extremities of the metacarpal bones. The radial artery
exits the Poculum-Diogenis
Diogenis space,
space and crosses the Ist interosseous space between the two
heads of origin of the adductor pollicis brevis muscle. In the palm, palm it has a transversal
trajectory, and it anastomoses next to the IVth interosseous space with the profound branch of
the ulnar artery.
-From
From the convexity of the arch
arch,the
,the four palmar metacarpal arteries arise, which
descend towards the root of the fingers along the interosseous space to anastomose with the
common digital arteries. From the palmar metacarpal arteries,
arteries three perforating arte
arteries
detach. These arteries cross the interosseous spaces,
spaces and anastomose with the dorsal
metacarpal arteries.
The profound motor branch of the ulnar nerve follows
-The follows the profound palmar
arch, and is innervating the last two lumbrical muscles, the interosseous
interosseous muscles
muscles, and the
adductor pollicis muscle.
 Practical references.
The arrangement of the synovial sheaths
sheaths, as well as the existing communications
between the superficial conjuctive spaces and the interaponeurotic spaces of the palm and of
the forearm, facilitate the propagation of the superficial infections of the fingers and palm
more profoundly. The synovial sheaths of the Ist and Vth finger follow the tendons with no
interruption.
Fingers II-IV
IV have their own synovial sheaths,
sheaths and their superior cul-de-sac
sac start from
the palm at the level of the „Kanavell” line
line, which connects the medial ends of the inferior
palmar fold with the distal head of the superior palmar fold.
The superficial palmar arch projects near the Böckel line. This is a transversal line on
the palmar face of the pollicis drawn in extreme abduction. The location of the arch
corresponds to the intersection between the Böckel line and the IInd metacarpal bone.
Regarding the palmar folds, the arch projects
proje at the bisecting line of the angle made by the
superior and middle palmar fold.
The profound palmar arch projects about 5-20 mm more proximally than the previous
one.
Surgically speaking, the most difficult territory of the palm called „the forbidden
territory” (Noli me tangere) is situated distal to the Kanavell line until the middle of the
fingers.
The sliding of the tendons of the fingers depends
depends on the integrity of this territory,
territory which
needs to be taken under special reconsiderations when performing surgical interventions
inte of
the hand.
The segments of the hand have a different value in prehension,
prehension which will be taken into
consideration when performing
rforming surgical interventions.

THE DORSAL REGION

REGIO OF THE HAND
(Dorsum manus)

Limits:superiorly, a transversal line above the pisiform bone; inferior

inferiorly, the line
between the metacarpophalangeal articulations. Laterally and medially
medially, the external margins
off the Ist and Vth metacarpal bone.
 The external shape. Under the skin, there are the metacarpal bones and the tendons of
the extensor digitorum muscle, which are separated through longitudinal grooves that
correspond to the intermetacarpal spaces. Also important, is the aspect of the venous network
of the back of the hand.
- With the pollicis in abduction,there can be observed the shape of the first dorsal
interosseous muscle in the Ist interosseous space.
- With the fingers in flexion, there appear 5 round proeminences, which correspond to
the heads of the metacarpal bones. The lines between the metacarpophalangeal articulations
project 1 cm inferiorly to these proeminences.
The covering layer.
- The skin is very thin and mobile. It presents numerous transversal folds with excess
tegument for the flexion movements of the hand.
- The subcutaneous tissue is reduced, lacks adipose tissue, and contains:
- The dorsal venous network of the hand, which forms the network of the fingers; it
is continued by the cephalic and basilic vein.
- The dorsal branch of the ulnar nerve is distributed to the skin from the medial half
of the region, and through the dorsal digital nerves to the last 5 margins of the fingers.
- The superficial branch of the radial nerve innervates the skin of the lateral half of
the hand, and the first 5 margins of the fingers are innervated through their dorsal digital
nerves.
- The dorsal fascia of the hand is a fibrotic and resistant blade; superiorly, it is
continued by the extensor retinaculum, and inferiorly, it merges into the dorsal aponeurosis of
the fingers.
- The tendinous layer is made out of the tendons of the following muscles, lateral to
medial:
- Musculus abductor pollicis.
- Musculus extensor pollicis brevis.
- Musculus extensor pollicis longus.
- Musculus extensor indicis which unites with the tendon for the indicis of the
extensor digitorum muscle.
- Musculus extensor digitorum, with four divergent tendons which have
intertendinous connections between themselves.
- Musculus extensor digiti minimi.
- Musculus extensor carpi ulnaris.
- These tendons are covered by synovial sheaths which ends approximately at the
level of the superior extremity of the metacarpal bones.
- Underneath the tendons for the pollicis, in the supero-external part of the region,
there is the insertion point of the two tendons of the extensor radialis carpi muscles.
The subtendinous layer is made out of a thin fibrocellular blade, called the dorsal
interosseous fascia, and also out of the arteries of the region.
- The radial artery has a very short trajectory on the back of the hand; in the
superior part of the Ist interosseous space, it perforates the dorsal interosseous muscle. Here,
it gives the dorsal artery of the pollicis, which descends along the Ist metacarpal bone
towards the dorsal face of the pollicis.
- The dorsal metacarpal arteries detached from the posterior carpal arch, descend
along the interosseous spaces, and are covered by the dorsal interosseous fascia. It
anastomoses with the perforating branches of the profound palmar arch, and it vascularizes
the back of the fingers.

THE ANTERIOR REGION OF THE FINGERS

 (Regio digiti anterior)

Limits: superior, the digito-palmar folds; on the sides, two vertical lines on the margins
of the fingers; profoundly, until the osteoarticular layer.
The external shape:The size and shape of the 5 fingers differs. When spread apart, some
folds can be observed at the root of the fingers, which are called the interdigital cummisuras.
Distally, they reach the middle of the proximal phalanx.
Each finger presents three proeminences corresponding to the body of the phalanx,
which are separated by double, or triple, folds. These folds are placed transversally; the
superior one corresponds to the digito-palmar fold, and the other two are interphalangeal
folds.
The proeminence of the last phalanx forms the fingertip, which has a characteristic
papillary design for every individual (the digital fingerprint).
The covering layer is made out of skin and subcutaneous tissue.
- The skin is thick, reduced and adherent to the underlying layers, especially at the level
of the folds. It presents the same characteristics as the tegument of the hand.
- The subcutaneous tissue has an areolar structure; it is crossed by vertical conjuctive
septums, which fix the dermis to the flexor sheath, divide the cellulo-adipose layer, and keep
it under tension. It is more abundant at the fingertip, and it is missing at the level of the
folds.In the subcutaneous tissue, the palmar vascular-nervous package of the fingers can be
found. It is made out of the proper digital arteries and nerves:
-The proper palmar digital arteries are branches from the common palmar digital
arteries, and they are located on the anterior margins of the fingers. They anastomose heavily
between themselves, and also with the dorsal arteries of the fingers. Like this, they around
them an arterial network. Due to the anastomoses between the common digital arteries and
the palmar metacarpal arteries, the vascularization of the fingers is made by both palmar
arches.
-The proper palmar digital nerves are placed together with the arteries, and they
innervate the skin from the anterior face of the fingers, and from the dorsal face of the last
phalanx. (For the first seven margins of the fingers the innervation is given by the median
nerve, and for the last three margins by the superficial palmar branch of the ulnar nerve.)
-Generally the nerves head along the fibrotic sheaths of the flexor digitorum
muscles, on their external surface, before the corresponding arteries.
- The osteofibrous canalof the fingers(the digital canal) is formed between the osteo-
articular layer and the fibrotic sheath of the flexor digitorum muscles. At the level of the
articulations, this canal has a weaker structure, and is strengthened only by the cruciate
ligaments. Corresponding to the phalangeal diaphysis, the sheath is strengthened by the
transversal, or annular ligaments. As such, it forms two pulleys: the first one is longer and
situated at the level of the Ist phalanx; the second one is smaller and situated at the level of
the IInd phalanx. The digital canal contains the tendons of the flexor muscles and their
synovial sheaths:
- The tendons of the flexor digitorum muscle – overlapped in the palmar region
at the level of the fingers; the tendon of the superficial flexor divides into two fibrotic
sheaths, which are placed laterally at the middle of the Ist phalanx. The tendon of the flexor
profundus muscle will pass through the tendinous space that is formed. The tendons are
attached to the mesotendons, between themselves, and to the underlying layer. The content of
the two pulleys is different:
- The first digital pulley, located at the level of the proximal phalanx,
contains the tendon of the flexor digitorum profundus muscle, and the two tendinous sheaths
of the superficial one.
 - The second digital pulley corresponds to the middle phalanx, and contains
only one tendon of the flexor digitorum profundus muscle.
- The digital canal of the pollicis contains only the tendon of the flexor
pollicis longus muscle.
- The digital synovial sheaths double the osteofibrotic canals, and are
surrounding the tendons until the distal phalanx. The synovial sheath of the Ist and Vth finger
is continued on the palm, while the synovial sheaths of the fingers II-IV end at the level of
the Kanavell line.
Practical references.
Even if they represent the lines of the flexion of the phalanx, the digital folds do not
correspond to the lines between the articulations. The digito-palmar folds are situated 15 mm
inferior to the lines between the metacarpophalangeal articulations, and the interphalangeal
fold are 5 mm more proximal to the corresponding interphalangeal articulation lines.
The position of the digital synovial sheaths determines how the infections spread. Due
to the continuation of the synovial sheaths of the fingers I and V, on the palm, and into the
carpal tunnel, infections can spread profoundly towards the Pirigov–Parona space from the
forearm. These two fingers, together with the sides of the palm, represent the dangerous „V”
of the hand.
The tendinous device of the fingers represents the fundamental component of the
region. When performing interventions,one will chose the location of the incision so that it
will not compromise the sliding of the tendons into their osteofibrotic tunnels. Functionally
speaking,the integrity of the tendon of the flexor digitorum profundus is of utmost importance
for the movements of the fingers, due to the fact that it is the main element of the flexion
movements. Practically, due to its central position, and to the divergence of the sheaths of the
tendon of the superficial muscle, the sectioning of the tendon on the fingers means the
sectioning of the flexor profundus muscle.

THE DORSAL REGION OF THE FINGERS

(Regio digiti posterior)

Limits:superiorly, a line that passes through the metacarpophalangeal articulations;

laterally and medially, the same lines as at the previous region; profoundly, until the
osteoarticular layer of the fingers.
The external shape:during the extension of the fingers, a series of cutaneous transversal
folds are formed; they are grouped at the level of the articulations of the fingers, and they
represent the reserve of skin for the flexion movements of the fingers.
- In flexion ,the head of the proximal and middle phalanx are visible as an edge.
- Almost half of the distal phalanx is covered by the nail (Unguis),which has the role of
protection and support of the fingertip, and is also useful in its tactile function. The nail is
made out of a body (Corpus unguis), which is colored in pink due to the transparency of the
vascular network situated under the nail, and is also made up of a root covered by skin; only a
small white area called (Lunula)remains visible. The skin crosses above the margins of the
nail making the nail wall (Vallum unguis), and underneath it, it has a fissure (Sinus unguis).
The covering layer.
- The skin is mobile.
- The nail is adherent to the underlying dermis, and is implaneted at the levels of the
root and margins into the matrix of the nail (Matrix unguis); it ensures the growth and the
regeneration of the nail.
- The subcutaneous tissue lacks fat, and it contains the dorsal vascular-nervous
package that the fingers are made out of:
 - The proper dorsal digital arteries, whichcome from the dorsal metacarpal
arteries, are situated at the postero-lateral margin of the fingers; they anastomose through
numerous arches with the proper palmar digital arteries. They are followed by a venous
network.
- The proper dorsal digital nerves com from the superficial branch of the radial
nerve for the first 5 margins of the fingers, and from the dorsal branch of the ulnar nerve for
the last 5 margins of the fingers. The skin of the terminal phalanx is innervated by the dorsal
branches of the proper palmar digital nerves.
The tendinous layer. In reality, on the dorsal face of the fingers II-V, the tendon of the
extensor digitorum widens at the beginning of the metacarpophalangeal articulation in order
to form an aponeurotic sheath. The tendon of the extensorum indicis, and that of the
auricular, fuse with the corresponding tendons of the extensor digitorum muscle.
- On the posterior face of the fingers, the tendons give lateral expansions that fix
around the metacarpophalangeal articulation, and fuse with the tendinous expansions of the
lumbrical and interosseous muscles. They also send a series of expansions for the dorsal face
of the three phalanxes, and for the capsules of the interphalangeal articulations.
- The tendons of the extensor pollicis longus and brevis muscles insert through some
fibrotic expansions on the entire dorsal face of the finger.
Practical references. During flexion of the fingers, the edges of the bones do not
correspond to the lines between the articulations, which are situated distally at about 8 mm
from the metacarpophalangeal line, at 4 mm from the proximal interphalangeal articulation
line, and at 2 mm from that of the distal interphalangeal articulation line.